> > 



i< a ^'> 



■>:vy> 


^ 

> 


> 

^ 


1- 


>3 


3 
D > 


3 






i> 


1 


i 


->> 
» 




■^ 


J> 


» 


D 


1 ^ 




> 




y 

^ 


:> ) 






■^ 


> ) 






-^ 








> 

■^ 


> >]> -^ 


) 










> ) 


^ 









LIBRAir^-4)F CONGRESS. 

Sheir -.MrA- 



UNITED STATES OF AMEllICA. | 






> i 



? -> ^ J 









y I 



PRACTICAL TREATISE 



DISEASES OF CHILDREN, 



PRACTICAL TREATISE 



DISEASES OF CHILDREN 



BY 

/ 

J. FORSYTH MEIGS, M.D., 

tK THE PHYSICIANS TO THE PENNSYLVANIA HOSPITAL; CONSULTING PUY'SICIAN TO TlIK 

children's hospital; fellow of the COLLEGE OF PHYSICIANS OF PHILADELPHIA; 

MEMBER OF THE AMERICAN PHILOSOPHICAL SOCIETY, OF THE ACADEMY OF 

NATURAL SCIENCES OF PHILADELPHIA, OF THE PATHOLOGICAL 

SOCIETY, OF THE OBSTETRICAL SOCIETY, ETC. ETC. 



WILLIAM PEPPER, A.M., M.D., 

\ 

PRDFESSOR OF CLINICAL MEDICINE IN THE UNIVERSITY OF PENNSYLVANIA; PHYSICIAN TO THE 

rNIVERSITY, TO THE PHILADELPHIA, AND TO THE CHILDREN'S HOSPITALS; FELLOW OF THE 

COLLEGE OF PHYSICIANS OF PHILADELPHIA; P^ESIDKNT OF THE PATHOLOGICAL 

>f>CIETY ; MEMBER OF THE AMERICAN PHILOSOPHICAL SOCIETY ; HONORARY 

MEMBER OF THE MEDICAL SOCIETY OF THE STATE OF NEW 

JER.SEY, OF THE OBSTETRICAL SOCIETY, ETC. ETC. 



i^th Edition, 

REVISED AXD ENLARGED. 



PHILADELPHIA: 
LINDSAY & BLAKISTON 

18 7 7. 

<7r 



4I' ^ 



^ 



Kntered according to Act of Congress, in the year 1877, 

By LINDSAY & BLAKISTON, 

In the Office of the Librarian of Congress, at Washington, D. C. 



■«lii.l;.M.\.N .^ (O., PRINTERS, PHILADELPHIA. 



^ 



TO 



GEORGE B. WOOD, M.D., LL.D., 

Prttident of the College of Physicians of Philadelphia ; Emeritus Professor of the Theory and 

Practice of Medicine in the Unix'crsity of Pennsylvania : late one of the Physicians 

to the Pennsylvania Hospital, etc. etc. 



A TIUDUTE OF RESPECT FOR HIS HIGH PROFESSIONAL ATTAINMENTS 

AND 

EMINENT PRIVATE VIRTUES, 

AND AS 

A MA1:K of (iRATITUDE FOR HIS VALUABLE INSTRUCTIONS, 

BY 

THE A U T li O R S, 

J. Forsyth Meigs, 
William Pepper. 



PREFACE 

TO THE SIXTH EDITION 



In preparing the present edition for the press, attention has been 
devotee! rather to the careful revision of the text than to the addition 
of new articles. A few have, however, been added, as upon Xiglit 
Terrors, and on Epidemic Cerebro-spinal Meningitis; while others 
have l>een rewritten, as in the case of the article on Cerebral Con- 
gestion. Wherever our own views have undergone modification since 
the publication of the last edition, it has been carefully noted ; and 
the attempt has been made to incorporate whatever is most important 
and trustworthy among the recent additions to our knowdedge of 
children's diseases. It is hoped that the thorough revision wliich lias 
thus l>een giv^en may entitle the present edition to as favorable a 
reception as has been accorded to its predecessors. 

Philadelphia, .January, 1877. 



PREFACE 

TO THE FIFTH EDITION 



Owing to the comparatively short time which has elapsed since the 
appearance of the last edition of this work, it has not been thought 
necess;iry to introduce any extensive changes in many parts of the text. 
All of it has, however, been subjected to careful revision, and such 
modifications made as were called for by changes in our own views, or 
by the results of the recent researches of others. In addition to this, 
several important articles have been almost entirely rewritten ; among 
which may be mentioned that on the Diseases of the Heart ; on Pro- 
gressive Muscular Sclerosis ; on the treatment of Scarlet Fever, and of 
Measles; on Variola, and on the Vaccine Disease. 

Some of the articles which seem appropriate in a systematic work 
on the diseases of children, but which were unavoidably omitted in 
the last edition, have been supplied. Among these will be found arti- 
cles on Pulmonary Emphysema, Pneumothorax, Affections of the Ton- 
sils, Retropharyngeal Abscess, Malarial Fevers, and Scrofula. To 
obviate the increase in the size of the work necessitated by these addi- 
tions, most of the illustrative cases, the number of which has been con- 
siderably increased, have been placed in smaller, type, and in many 
places the former text has been condensed. Despite these changes, 
however, an increase of ninety pages has resulted from the large amount 
of new matter added. On the whole, it is felt that the hope may rea- 
sonably be entertained that the work in its present form will prove of 
more practical utility than heretofore, and will continue to serve the 
purjxjse, which has actuated its authors, of facilitating the study and 
treatment of this interesting and important class of diseases. 

PiiiLADBLPHiA, January, 1874. 



TABLE OF CO]S^TENTS, 



PAGE 

Preface to the Sixth Edition vii 

Preface to the Fifth Edition ix 

Introductory Essay. 17 



CLASS I. 

DISEASES OF THE RESPIRATORY ORGANS. 

CHAPTER I. 

diseases of the upper AIR-PASSAGES. 



Article I. Cor}-za. 



SECTIOX I. 

SECTIOX II. 

diseases of the larynx. 

General Remarks, 

Article I. Simple lar}-ngitis without spasm, 

" II. Spasmodic simple laryngitis, . 

III. Pseudo-membranous lar3-ngitis, 



51 



59 

»i7 

83 



CHAPTER II. 
diseases of the lungs and pleura. 

General Re3£arks, 

Article I. Atelectasis pulraonum. 

" II. Pneumonia 

'' III. Bronchitis, . 

IV. Emphysema, 

V. Pleurisy, 

VI. Pneumothorax. 
• VII. Ilooping-cougli 



129 
130 
153 
IIK) 
213 
226 



XU TABLE OF CONTENTS. 



CLASS 11. 

DISEASES OF THE CIRCULATORY ORGANS. 

PAGE 

x\.RTiCLE I. Cj^anosis, 276 

" II. Diseases of the heart, 284 



CLASS IIL 

DISEASES OF THE DIGE":»TIVE ORGANS. 

CHAPTER I. 

DISEASES OF THE MOUTH AND THROAT. 

Article I. Shnple or erythematous stomatitis, 296 

II. Aphthse, 297 

'-'■ III. Ulcerative or ulcero-inembranous stomatitis, . . . 300 

" ly. Gangrene of the mouth, 304 

V. Thrush, 315 

" YI. Aflfections of the tonsils, 342 

" yil. Simple or erythematous pharyngitis, .... 346 

** VIII. Retropharyngeal abscess, . 351 

CHAPTER II. 

diseases of the stomach and intestines. 

General Remarks, 353 

SECTION I. 

functional diseases or mild catarrh of the stomach and 

intestines. 

Article I. Indigestion, 353 

" II. Simple diarrhoea, 364 

sectio:n" II. 

diseases of the stomach and intestines, attended with appre- 
ciable ANATOMICAL ALTERATIONS. 

Article I. Gastritis, 374 

" II. Entero-coiitis, or inflammatory diarrhoea, . . . 380 



TABLE OF CONTENTS. 



Xlll 



Article III. Cholera infantum 

"• IX. Dysentery 

'' V. Diseases of the ca'cuni and appendix ccvci, 

VI. Intussusception, 



PAOF. 

416 
436 
441 
456 



CLASS IV. 



DISEASES OF THE N37.V0US SYSTEM. 



Gen-eral Kkmarks, 

Article I. Tubercular meniniiiti; 



II. Simple meningitis, 

III. Cerebral congestion, . 

IV. Cerebral hemorrhage, 
V. Chronic hjdrocephalus, 

VI. General convulsions or eclampsia 

VII. Larynirismus stridulus. 



VIII. 

IX. 

X. 

XI. 



Contraction with rigidity. 



Tetanus, .... 
Chorea, . . . . , 
Atrophic infantile paralysis, 
XII. Facial paralysis, 
XIII. Progressive muscular sclerosis 

muscular paralysis, 
XrV. XiLrht terrors. . 



pseudo-hypertrophic 



472 
473 
503 
510 
513 
522 
532 
550 
567 
576 
584 
609 
626 

628 
639 



CLASS V. 



GENERAL DISEASES— CONSTITUTIONAL AND ZYMOTIC. 
IXTRODUfTORY REMARK.S, . 

Article I. Rheumatism, 

II. Diphtheria. 

III. Mumps, 

IV. Malarial fever, 
V. Epidemic cerebro-spinal meningitis, 

VI. Scarlet fever, or scarlatina, 

■ VII. Mea.Hles, or rubeola, or morbilli, 

■ VIII. Small-pox, or variol I 

IX. Vaccine disea.«e, 

X. Varicella, 

XI. Typhoid fever 



645 
('45 
651 
6S5 
689 
61 c; 
7< )J 

:•;} 

7s7 
809 
>Jl 



XIV 



TABLE OF CONTENTS. 



CLASS VI. 

CACHECTIC DISEASES. 

PAGE 

Article I. Scrofula, 842 

" II. Tuberculosis, 848 

" III. Kickets, 863 

" ly. Congenital syphilis, 875 

CLASS VI L 

DISEASES OF THE SKIN. 
INTRODUCTOIIY REMARKS, 882 

CHAPTER I. 

RASHES. 

Article I. Erythema, 883 

" II. Erysipelas, 888 

" III. Roseola, 896 

" ly. Urticaria, . . . . . . . . . .899 

CHAPTER II. 

VESICLES. 

Article I. Eczematous affections, . ... . . . . 903 

" II. Herpes, 918 

" III. Scabies, 923 

CHAPTER III. 

BULL^. 

Article I. Pemphigus or Pompholyx, 928 

" II. Rupia, . 930 

CHAPTER IV. 

PUSTULES. 

Article I. Ecthyma, 933 



TABLE OF CONTENTS. XV 

CHAPTER V. 

PAPULES. 

PACE 

Article I. Strophulus, 936 

TI. Lichen, 937 

•• III. Prurigo, 939 

CHAPTER VI. 
Sfiuamre. . ' 940 

CHAPTER VII. 

DISEASES yOT CLASSIFIED AMONG THE PRECEDING. 

SECTION I. 
parasitic diseases of the skin. 

General Remarks, 942 

Article I. Favus, 946 

II. Tinea, 953 

III. Alopecia areata, .... . . 958 

SECTION II. 
Article I. Sclerema, 960 



CLASS VI 1 1. 

WORMS IN THE ALIMENTARY CANAL. 

General Remarks 905 

Article I. Ascari.s lumbricoides, 909 

*' II. Ascaris vermiculari.s, 981 



A 

PRACTICAL TREATISE 

OK THE 

DISEASES OF CHILDREN, 



INTRODUCTORY ESSAY. 

•% 
ON THE CLINICAL EXAMINATION OF CHILDREN. 

The clinical examination of children, and particularly of young infants, 
cannot be successfully practiced upon the same method as that habitually 
made use of in the case of adults. The truth of this statemeut will be 
readily assented to by all who have had much experience in the treatment 
of the diseases of the two ages, by those who will reflect for a moment on 
the great differences in the expressions of the various organs in early and 
adult life, and by those who are acquainted with the opinions of distin- 
guished writers upon children's diseases. It is proper and useful, there- 
fore, to preface a practical work on the diseases of children, with a sketch 
or plan of the best method to be pursued in forming a diagnosis of these 
diseases, and with remarks upon the physiological characters which dis- 
tinguish the organization of early life from that of maturity. 

The difficulties that beset the path of the practitioner in his clinical ex- 
amination of children are so great that he who has not been prepared by 
preliminary study to surmount these obstacles, will find it a most uncer- 
tain and dubious t^usk to unravel the history and nature of any case that 
may be set before him. The helpless silence of the infant, — the wilful 
silence, or the loose and inconsistent answers of the older child, which lead 
astray the mind rather than guide it to true results, — the agitation and 
fright produced by the examination, rendering it impossible at times to 
ascertain the real state of the different functions of the economy, — and, 
lastly, the difficulty of obtaining accurate and reliable accounts of the his- 
tory of the case from the attendants, all combine to make the duty of the 
physician most perplexing, and, unless he be gifted with a large share of 
patient and philosophic calmness, most irksome and trying to the temper. 

2 



18 INTRODUCTORY ESSAY. 

So great, iudeed, are the difficulties encountered by some practitioners who 
enter upon this branch of the practice of medicine without proper prelim- 
iujirv preparation, that they never overcome them ; but, to use the words 
of Dr. West, " grow satisfied with their ignorance, and will then, with the 
greatest gravity, assure you that the attempt to understand these affections 
is useless." That it is possible, however, to overcome, in great measure, 
these obstacles, and to arrive at a correct diagnosis in nearly all cases, is 
quite as true as that these obstacles really exist. But, in order to do this, 
the physician must first be aware that difficulties exist, and must have 
formed in his mind some plan or method by which to surmount or elude 
them. 

Before proceeding to show what is the best method of examining or ex- 
ploring disease in children, we must state that our remarks apply chiefly 
to infants and very young subjects ; for, after the age of eight and ten 
years, the physical and intellectual development have progressed to such 
a point as to render the method of diagnosis nearly the same as that em- 
ployed in adults. 

The chief causes which render the diagnosis of disease in young chil- 
dren difficult, are the absence of the faculty of speech, and the violent 
agitation generally caused by the examination, which prevents a proper 
appreciation of the state of certain organs and functions. 

It is easy to understand how much our means of diagnosis are restricted 
by the absence of the faculty of speech. How many symptoms are there 
in the case of adults with which we become acquainted only through the 
patient's own account of his sensations ; and, consequently of how many 
must we be deprived in children by the absence of this account. It might, 
indeed, at first view, seem impossible to detect the nature of the sickness 
without the assistance of this means, so greatly do we depend upon it in 
our examination of adults. Nevertheless, we shall find ourselves enabled, 
by an attentive consideration of other resources in the child, by a close 
study of its physiognomical expression, its decubitus, the nature of its cry, 
and by the most rigidly careful physical examination, to form our conclu- 
sions with almost as great a degree of precision as in older patients. 

The other causes of difficulty, — the violent disturbance, both physical 
and moral, of the child, its fright, agitation, and cries, — constitute, when 
they are present in a high degree, much greater embarrassments than the 
want of speech. To overcome these, the physician must use all his skill, 
tact, and patience ; for, unless they can be avoided by art, or overcome by 
soothing and gentle persuasion, he can learn but little that will be of 
essential service to him in making up his opinion. He can neither read 
the countenance of the little patient, nor judge by its attitudes or decu- 
bitus of the state of the various organs, whether internal or external ; he 
will be unable to ascertain the rate, force, or regularity of the circulatory 
or respiratory functions ; he cannot, to any useful purpose, examine the 
abdomen, to learn whether it be tender on pressure, or whether its con- 
tained organs be in their natural condition as to size and ppsition ; and, 
lastly, he will find that the physical exploration of the lungs and heart, 
by auscultation and percussion, yield him at best only imperfect results. 



METHOD OF DIAGNOSIS. 19 

To avoid the difficulties just detailed, it is always useful, if uot abso- 
lutely uecessary, to couduct certain portious of the examiuatiou whilst the 
child is calm and quiet, and certain othei-s whilst it is disturbed and 
agitated. This distinction of the examination into two periods, or stages, 
is one of the utmost importance in a practical point of view, and should 
never be forgotten by the physician during his clinical observation of the 
various symptoms the patient may present. 

By the period of calm is meant a condition of total quiescence, in which 
the child is undisturbed either by internal or external causes of irritation. 
This condition is best found in the state of sleep. If this cannot be ob- 
tained, the one most nearly approaching to it is that which exists during 
the act of nursing, or which follows that act. Suckling is usually followed, 
even in the sick child, by a condition of drowsiness or by a gentle and 
languid :^lumber, during which it will allow a careful examination upon 
many points without agitation. If possible, therefore, the physician should 
always see the child when asleep, and if the mother or nurse propose, on 
the occasion of his visit, to hurry upstairs to prepare the child, or to bring 
it down into the parlor or lower room, he should ask, as a favor, that he 
may see it asleep. 

If, in spite of having just been nursed, the child be awake and fretting, 
and when, also, it is more advanced in age, we should endeavor, by the 
attraction of toys, by gentle and soothing words and manners, by fondling, 
or by having it carried about the room, to get it quiet. 

Before proceeding to a consideration of the particular means by which 
we are to judge of the state of health or sickness of young subjects, it is 
proper to call attention to the great importance of a careful examination 
of the attendant's, in regard to the history of the case, previous to and 
between the medical visits. In the instance of children, their inability to 
describe their own symptoms compels us to depend entirely upon the mother 
or nurse for all detail of the case previous to our first visit, and for all ac- 
counts of what may have happened between two subsequent ones. It is, 
therefore, extremely important that this part of the examination should be 
conducted with every care and caution. Very much that is useful may be 
learned from it, if it be well managed. A great deal of skill and art are 
required in putting the questions, and in sifting the evidence thus collected. 
We should always bear in mind the character of the persons questioned. 
Much depends upon their education, and much more on their natural 
powers of observation, and manner of relating what they may have seen. 
The degree of credence to be attached to their answers must rest u\h)ii 
their probable intelligence. Nurses and mothers will often give accounts 
of their charges which must be received with large allowance, and even in 
some few instances with disbelief. We would, however, in this place, most 
earnestly caution the young practitioner of medicine to be very careful not 
to misbelieve, or even mistrust, without well-poised reasons, the account of 
a sick child given by a mother; for though a foolish, weak woman will 
often give a false or exaggerated statement of the symptoms of her child, 
an observant and intelligent, and sometimes a foolish and weak ono, when 
guided by maternal instinct, will detect variations from the healthful con- 



20 INTRODUCTORY ESSAY. 

dition of the child, which may entirely escape the search of the most acute 
and rigorous medical observer. A mother may perceive a change in the 
expression of the face, in the manner of the muscular movements, in the 
temper or conduct of her child, which shall fail to attract the attention of 
the practitioner ; or it may be that the symptom which has caused the 
parent to take alarm occurs only during the absence of the physician. 
The medical attendant ought, for these reasons, to listen patiently and 
kindly to whatever the mother or nurse may have to say, and if unable to 
detect immediately what they assert they have seen, let him not determine 
at once that there has been a mistake, that their anxiety has deceived them ; 
but let him examine the patient yet again, and more carefully, or let him 
pay another visit to learn whether the symptom or symptoms continue, or 
have occurred again. Our own rule, in a doubtful case, is to listen with 
religious attention to the mother, and unless she be far beneath the average 
of human intelligence, our opinion as to the fact of some deviation from 
the ordinary health of the child is considerably influenced by what she 
tells us. 

The inquiry in regard to the history of the case, previous to the first visit 
of the physician, should bear particularly upon the causes of the sickness, 
its precise moment and mode of attack, and its course and symptoms up to 
the present time. The most important points to be considered in connection 
with these objects, are the health of the parents, including their ordinary 
health, or their habitual diseases, the causes and periods of their death, if 
they are not living, and the state of health of the- child at the moment 
of birth and since. The hygienic conditions in w^hich the patient has been 
placed ought always to be investigated ; the place of habitation ; the kind 
of house, and whether a large well-ventilated room, or a small, narrow, and 
close one ; the clothing ; the food ; and lastly, whether the infant has been 
suckled, or brought up on artificial diet. The state of the health just 
anterior to the attack ought always to be examined into. Has it been 
good and strong, or feeble and delicate? If delicate, what diseases? If 
the approach of any of the eruptive fevers be suspected from the character 
of the symptoms, the question as to whether the child has previously had 
measles or scarlet fever, or has been vaccinated or had variola, should 
always be asked. 

It is next necessary to fix as accurately as possible, the precise period of 
the onset of the sickness. If the question, " When was the child taken 
sick?" be asked, as it usually is, the answer will be, "Oh, several days 
ago," or, " I don't recollect exactly—I think yesterday, or the day before," 
or some such loose answer. The best way to learn the exact period in a 
recent case, is to go back, day by day, or else to inquire as to some par- 
ticular day. We may ask, was the child quite well day before yesterday ; 
was it well last Sunday ? did it play and amuse itself? was it as gay and 
good-tempered as usual yesterday, or the day before, or the day before 
that? Did it sleep well night before last, or the night before that? A 
sick child never scarcely sleeps well at night, and very often we may learn 
by close inquiry into this particular, the exact time at which the attack 
began. In this way, by forcing the attendant to tax her memory, and to 



DIAGNOSIS OF ANTECEDENTS. 21 

go minutely over the events of the several days previous, we shall nearly 
always succeed in fixing very precisely the moment of onset. 

Having determined these points, we should proceed to inquire in regard 
to the course of the disease prior to the first visit. This is to be done only 
by patient and repeated questioning. The questions must be so framed as 
to elicit free and unbiassed answers. They should be general, and not 
leading. Lastly, we are to inquire into the treatment of the case up to 
the present time. 

It is best that all these interrogatories should be made previous to see- 
ing the child, in some other room than the nursery, in order to avoid the 
risk of alarming the child by the presence, during an unnecessary length 
of time, of a stranger. If, however, the child be well acquainted with the 
physician, it matters not where the inquiries are made. 

Having now obtained from the attendants all the information they can 
give in regard to the history and nature of the case, the physician must 
proceed to the personal examination of the patient, in order to determine, 
by his own observation, the exact nature of the sickness, and the treat- 
ment it may require. 

The most important points to be attended to during the clinical exam- 
iDatioD,are the countenance or faciei, noting its expression, coloration, the 
presence or absence of furrows and wrinkles from pain, from emaciation, 
or from disordered muscular action, the appearances presented by the nasal 
orifices, and especially by the alse nasi, and the characters exhibited by the 
mouth ; the sleep ; the cry ; the state of embonpoint or emaciation ; the 
condition of the skin as to coloration, temperature, moisture or dryness, 
the presence of swellings of any kind, such as those produced by dropsy 
or by aflfections of the joints, and the existence of eruptions ; the pulse ; 
impulse of the heart ; the respiration ; the signs furnished by the state of 
the mouth and throat, and by the disposition towards and power of suck- 
ing, or by the manner in which drinks are taken ; and lastly, the state of 
the abdomen. 

The O'UXTenan'ce. — The countenance of a young and healthy infant, 
who is sleeping or perfectly quiet, wears no expression except that of com- 
fort and content. It is composed and still ; no movement disturbs its in- 
nocent tranquillity, unices, perhaps, some gentle smile light it up from time 
to time, when we might well believe the happy superstition of the fond 
mother, who will tell us that angels are whispering it. In sickness, even 
when slight, the countenance .«oon loses this expressionless character. In 
all acute disorders the alteration is very great, such indeed as to strike the 
most careless and inexperienced observer. The features become contracted, 
furrow.s and wrinkles appear about the forehead, the nostrils are dilated, 
or pinche<l and thin, and the mouth liecomes drawn and rigid. The extent 
of the change is generally in proportion to the severity of the attack. The 
part of the face most altered will depend very much upon the particular 
system of organs implicated in the disease. 

Some authors have endeavored to show that different diseases give to 
the physiognomy certain peculiar and characteristic exjfrr.t'ilons. This is 
true onlv to a certain extent. Thu', the fades is vtrv diflerent in abdom- 



22 INTRODUCTORY ESSAY. 

inal from that observed in thoracic or cerebral diseases ; but though it is 
(jencra/h/ easy for a practiced physician to distinguish by the facies alone 
between a cerebral and thoracic disorder, it is quite impossible for him 
to distinguish between any two cerebral, thoracic, or abdominal affections. 
The particular changes impressed upon the face by different diseases can- 
not, however, be discussed in this place, but must be considered in the sepa- 
rate articles upon each disease. Here it can only be stated in general 
terms, that, in diseases of the brain, the upper part of the face, the fore- 
head, and the eyes are chiefly affected ; that in diseases of the thoracic or- 
gans, the middle portion of the face, and especially the nostrils ; while in 
those of the digestive organs, the lower part of the face, the mouth and 
lips, are the parts which undergo the greatest changes in their expression. 

Paiji may almost always be detected by the expression of the face. It 
gives to the countenance various shades of expression, according to its de- 
gree of severity, and its permanency or recurrence at intervals. Pain in 
the head is said, by Dr. M. Hall, to produce a contracted brow, pain in 
the belly to occasion an elevation of the upper lip, whilst pain in the 
chest is chiefly denoted by sharpness of the nostrils. We doubt, however, 
whether pain in any particular organ imparts an expression to one part 
of the face rather than to another, for indeed pain in any part of the body, 
whether the head, chest, abdomen, or limbs, gives rise to a contraction of 
all the features. Not one part of the face alone, but the forehead, mouth, 
nose, and the whole face, become changed in expression and contracted, 
when there is severe pain in any part of the body, so that we deem it im- 
possible from the expression alone, to determine where the painful sensa- 
tion may be seated. The countenance merely tells us there is pain, but 
not where it is located. The painful expression will be permanent or oc- 
casional, as the pain itself is constant or only paroxysmal. 

The coloration of the face becomes often an important means of diagnosis. 
In all the fevers, phlegmasise, and diseases of general excitement, the face 
will be more or less suffused and red, unless the attack be so severe as to 
occasion a violent shock to the nervous system, in which event the counte- 
nance instead of being suffused, is paler than natural. In such cases the 
face becomes of a dead white, all traces of red disappear, and the skin at 
the same time has often a slightly shining or varnished appearance. We 
have not unfrequently observed this symptom in pneumonia and bron- 
chitis, and also in the latter stages of true croup. It is a very striking 
phenomenon, and one which portends great danger. 

^ In chronic eases of all kinds in which the hematosic and nutritive func- 
tions are enfeebled, the face assumes a pallid and waxen hue, which is very 
characteristic. In the various digestive ailments it becomes icterode or 
sallow, and iu affections of the liver more or less yellow. Lastly, in cer- 
tain diseases and malformations of the heart or lungs, it becomes bluish 
or livid, constituting one of the most important signs of what is called 
morbus ca-ruleus, blue disease, or cyanosis. 

In reading the countenance of a sick child, the practitioner should 
always notice the play of the nostrils, since this reveals, to a certain ex- 
tent, the state of the lungs. In pneumonia, bronchitis, and pleurisy, the 



SIGNS FROM THE SLEEP. 23 

movements of the alie nasi become rapid and energetic, expressing, by the 
degree of their violence and extent, the amount of embarrassment under 
which the respiratory function is hiboring. 

The nostrils and nasal passages should always be examined also to ascer- 
tain the presence of mucous or purulent secretions, or of pseudo-membra- 
nous deposits, since these fluids or their inspissated products interfere more 
or less with the free passage of air through those canals. 

Of the Sleep. — Much useful information as to the state of health of 
infants and children may be obtained from a careful consideration of the 
various phenomena connected with their sleep. Of this we are fully con- 
vinced from somewhat long and patient observation. We cannot ascer- 
tain, indee<i, the nature of the disease under which the child may be 
laboring, but we can detect, with very great certainty, the existence of a 
deviation from health. We know of few more certain means of fixing 
the {period at which any attack of illness may have begun, than by in- 
quiring at what time the child began to have restless or broken sleep, or 
insomnia. 

A perfectly healthy infant, within the month, who is suckled at an 
abundant and wholesome breast, will usually sleep twenty out of the 
twenty-four hours, waking to nurse every two or three houi-s during day- 
light, and twice or three times during the night. After the age of two or 
three months, the child is much more wakeful during the day, though it 
will still take a nap of two or three hours in the morning, and a shorter 
one in the afternoon, while it will sleep from early evening until the fol- 
lowing morning, waking but once or twice to suck. Indeed, many per- 
fectly healthy infants, of between three and six or seven months of age, 
sleep without waking from nine or ten o'clock in the evening until six the 
next morning. After the latter age the sleep is seldom so unbroken ; the 
child begins to undergo the first considerable trial to its health, dentition, 
and it is rendered thereby more or less ailing and . irritable, and conse- 
quently restless and troublesome at night. 

Children who have passed through the .epoch of dentition, and who are 
perfectly welf, usually go to sleep soon after being put to bed, and never 
wake until the following morning. Not only so, but they sleep soundly 
and quietly, without being disturbed by slight sounds, and without tossing 
or turning much in their sleep. 

In healthful sleep the whole appearance of the child, its expression of 
countenance, its attitude, and its breathing, all declare a most perfect and 
beautiftil ease and tranquillity. Nothing can be more suggestive of the 
comfort and well-being that naturally attend upon health, than the per- 
fect composure and graceful postures exhibited by a hearty child during 
profound sleep. 

It needs, however, but a slight di.«turbance of the health of a child to 
break in upon its ordinarily calm and peaceful sleep, and to render this 
restless, fitful, interrupted by startings, cries, or dreams, or insufl^cient. 
The mo8t trifling irritations, as the pres-sure of a tooth against the gum, 
the presence in the digestive canal of a little imperfectly digested fooil, or 
of one, two, or three lumbricoides, or the slightest fever from any cause, 



INTRODUCTORY ESSAY. 



are sufficient to produce this effect, and hence it is that the character of 
the sleep will often become to a watchful practitioner the first sign of dis- 
order held out by nature. 

The degree of disturbance of this function will vary with the nature 
and severity of the disturbing cause. When slight, the child will con- 
tinue to sleep throughout the ordinary period, but the sleep will be some- 
what uneasy. The countenance will be disturbed. There will be contrac- 
tions of the brow, and momentary workings of the features, which express 
the perception of some unhealthful sensation. Often the child will toss 
and turn, and change its position more frequently than natural. Some- 
times it wMll cry out, and appear distressed by some dream or painful sen- 
sation. When the cause of disturbance is more serious, the sleep is more 
broken, the child wakes often, and lies awake for a longer or shorter time, 
and it becomes very difficult to lull it to sleep again. Or it has painful 
dreams or nightmare, causing it to scream and struggle in sleep, and then 
to wake in the most violent affright. In severe instances it becomes almost 
sleepless. We have very often known teething children not to sleep more 
than half as much as in health, and to wear out, by the long continuance 
of this sleeplessness, the patience and even the health of their attendants. 
In some instances they will no longer sleep in the bed or crib, and the 
nurse is obliged to get up and w^alk with them, or soothe them by the 
movement of a rocking-chair or cradle. In other cases, the derangement 
of the health is shown by grinding of the teeth, and by the most violent 
tossing and tumbling about the bed. We have frequently seen a child 
lying with its head where its feet should be, or across the bed, and with 
all the coverings thrown off, in spite of the most careful arrangement of 
the bedclothes. 

These various disturbances are therefore signs of some alteration in the 
health of the child. They do not lead to an appreciation of the precise 
nature of that alteration, but they are invaluable as affording indications 
of the existence of some morbid condition of the economy. Very often, 
as above stated, they are the first symptoms of the approach of some more 
or less serious sickness, and as such will often enable us to determine, with 
much precision, the moment of onset of the attack. 

The Cry.— Crying is one of the modes of expression of the child. In- 
deed, this, with the expression of the face, are, according to M. Billard, 
the only means of expression with which nature has endowed the young 
infant. This is, however, scarcely correct, since we may also class amongst 
its means of expression the various spontaneous muscular movements in- 
dicative of uneasiness, or of pain, or pleasure ; the manner in which it 
drinks or sucks, whether eagerly, and with appetite, or languidly, or care- 
lessly, or not at all ; the enjoyment it receives from pleasant sounds ; and 
the evident delight it takes in regarding the light. Nevertheless, the cry 
and the expression of the countenance are the two means on which the 
physician must chiefly rely for early information of the occurrence of sick- 
ness in the young infant. These are the trusty sentinels of nature. By 
them she first gives notice of the approach of danger, and then measures 
the amount of mischief that may have been done. 



SIGNS FROM THE CRY. 25 

The cry which a child utters during sleep, or even when awake, and when 
nothing has been done to excite or disturb it, is always indicative of some 
uneasiness. If the cry be caused by pain, or by any considerable disturb- 
ance, it will be accompanied by certain contractions of the features and 
movements of the body and limbs, which will still more strikingly show 
that the pain, or other exciting cause, is of a serious nature. Violent and 
obstinate crying is almost always caused by severe pain, — such as the pain 
of earache. Indeed, obstinate and long-continued crying, lasting for hours, 
is rarely met with except from one of two causes, earache or hunger. The 
cry of earache is often incessant and unappeasable, the pain being gener- 
ally constant and not paroxysmal, as are most other pains. It is to be 
silenced only by the application of remedies to the ear, or by the internal 
administration of opiates. We have known an infiint, three months old, 
to scream with earache for two days and nights, with only short lulls of a 
few hours when brought under the influence of large doses of laudanum. 
As soon as the ear began to discharge, the cry ceased. We are constantly 
called to see infants and young children who have been crying most vio- 
lently for hours, and who are thought to have colic, or to have hurt them- 
selves, but who are, in fact, tortured with that most violent of all pains, 
earache. We have met with few instances in which such severe and constant 
crj-ing has depended on other causes ; for, though children scream vio- 
lently and obstinately from hunger and thirst, they may always be quieted 
by the supply of either want, whilst in earache the infant generally refuses 
the breast, or takes it only for a few instants, and then lets go to resume 
his almost automatic scream. 

To show the difficulty of sometimes determining the cause of crying, we 
may mention that one of us once attended a nursing baby through a severe 
attack of bronchitis. Just as the child was recovering from the attack it 
began to cry without any apparent cause. The cry was so constant, vio- 
lent, and severe, that, feeling certain from the -ymptoms that it could not 
be from any dangerous cause, we concluded, by the method of exclusion, 
though, to be sure, there was neither tenderness of the ear to touch, red- 
ness or swelling of the meatus, nor discharge, that it must be an earache. 
Hot applications and opiates applied to the ears did no good, and the con- 
stant scream set the mother half wild. At length, the grandmother came 
in and said she thought the child wanted the breast. Sure enough, there 
was the trouble ; the child lay at the breast almost continuously for twenty- 
four hours, and earache, crying and all, vanished. 

In not a few instances we have thus known infants to cry very often in 
the day and night, and .sometimes very obstinately, too, from hunger. In 
such cases the child is thought to have colic, and as it is not unfrequently 
costive, it is dosed with cathartics, carminatives, and opiates; or it is being 
brought up partially or wholly upon artificial diet, and, as a consequence, 
ha.« some disorder of the bowels, which is thought to require other kinds 
of medicaments for its relief When the stools are natural in appearance, 
or merely costive, and when the child does not labor under flatulence, it is 
ea.«y, by careful questioning of the mother, to discern whether she has milk 
enough, and by examination of the size and weight of the child, to judge 



26 



INTRODUCTORY ESSAY. 



whether growth aud nutrition go on in their proper ratio ; and if it be 
found that the mother is a poor nurse, and that the development of the 
chikl is sK)\v and imperfect, we should at once direct an additional supply 
of uourifihment, and the suspension of all mere drugs. We have often 
been surprised and delighted to find how soon, under the new treatment, 
the child becomes placid and comfortable, how well and how long it sleeps, 
and at what a rapid rate it develops its form and size. So, when the cir- 
cumstances above referred to coincide with a somewhat disordered state of 
the bowels, we should first choose for the child the diet most appropriate 
to its age and state of health, and then, if after inquiry it appears that the 
whole quantity taken in the twenty-four hours is below the proper standard, 
the amount allowed must be augmented. 

The crying occasioned by pain in the head, by the pain which accom- 
panies pneumonia or pleurisy, or that which is attendant upon abdominal 
inflammations, is never scarcely constant, though it may be violent while 
it lasts. 'Pain in the head usually causes a sudden and sharp cry or shriek, 
which is over as soon almost as heard, and which has been called the hydren- 
cephalic cry. The pain of pneumonia, which, it should be remarked, is 
not unfrequently absent, or so slight as not to be noticed, commonly 
occasions crying only during coughing, and for a short time after, and is 
accompanied by distortion or grimacing of the features. In pleurisy, 
again, the cry is also heard generally at the moment of coughing, but it is 
produced also by the act of moving the child, and by pressure on the affected 
side. It is commonly much louder, shriller, and indicative of greater suf- 
fering than in pneumonia, and in some cases that we have seen, has been 
very frequent and difficult to appease. 

The cry of intestinal pain may almost always be recognized by the fact 
that it takes place just before or after a stool, that it is accompanied by 
wriggling and twisting movements of the trunk, and especially of the 
pelvis, or, in very young infants, by its coincidence with more or less flatu- 
lence, which is revealed by a tympanitic condition of the abdomen, and 
by frequent regurgitations of gas. 

Children not unfrequently cry much and very obstinately from mere 
fretfulness and general distress or malaise. This kind of crying may be 
recognized by its peculiar tone, which is short, sharp, and irritable. It 
is a fret rather than a scream ; it is occasioned by the least disturbance 
offered to the child, by the attempt to move it, to dress it, to attend to any 
of its wants, even to look at or notice it; it is moreover possible, generally, 
to still such a cry by soothing treatment, or by the endeavor to amuse the 
little thing with toys. 

Lastly, a child will sometimes attempt to cry, but is unable to utter any 
or only a very faint sound. This depends commonly upon some laryngeal 
impediment, but may be also the result of pure exhaustion ; there is not 
suflficient strength to sound a cry. 

The cry of the young child has been divided by M. Billard into the cry 
proper and the return ; and inasmuch as these two portions of the cry are 
differently affected in different diseased conditions, it is important that we 



GENERAL APPEARANCE — DEVELOPMENT, ETC. 27 

should be aware of their existence, and of the effects produced upon their 
mauife^itations by disease. 

The cry proper is produced during the act of expiration, while the return 
occurs during inspiration. The cry proper is sonorous and prolonged, the 
return is much shorter and sharper. The return is feeble in young infants, 
and becomes stronger as they advance in age. In different states of health, 
the mode of crying will vary to a considerable extent. The cry may exist 
alone, or in combination with the return ; or again the return only may be 
heard, whilst the cry is from some cause suppressed. The distinction be- 
tween the two portions of the cry may always be distinctly perceived in a 
child who is crying violently from any recent cause, whether ill-temper, 
fright, or pain, unless one or other has been suppressed by some morbid 
condition which interferes with the perfect performance of the vocal func- 
tion. After a time, however, when the infjint has become fatigued with its 
efforts, the cry proper ceases in part, and we have only the return, which 
is heard from time to time between the sobs. According to M. Valleix, it 
is the return which becomes enfeebled and disappears first, whenever one 
portion only of the cry is heard. Towards the fatal termination of all dis- 
eases, the return ceases more or less completely, and the cry assumes a 
peculiar moaning or murmuring character, which must be familiar to all 
who have been much in the sick-rooms of children. 

With a remark upon the condition of the lachrymal secretion in disease, 
we shall conclude this division of the subject. 

The infant does not begin to secrete tears until towards the third or 
fourth month, and of course this function can furnish no sign previous to 
that time. After that period, however, the suppression of this secretion 
becomes, according to M. Trousseau, a valuable aid to prognosis, as this 
suppression occurs generally in all dangerous acute diseases. The occur- 
rence of this symptom in any acute case should be looked upon, therefore, 
as one of dangerous augury, while the continuance of the secretion, or its 
reappearance after it has been suppressed, is, on the contrary, a highly 
favorable omen. 

General Appearance of the Child ; Development ; Embon- 
point ; State of the Skin, Etc. — While occupied in hearing the account 
of the sickness given by the mother or attendants, and even while asking 
questions in regard to the present state of the patient, the physician may 
learn a great deal that is useful by an attentive observation of the general 
appearance of the child as it lies before him. He should study its size and 
development, its state of embonpoint or emaciation, its decubitus and ges- 
tures, the color, temperature, and dryness or humidity of the skin, and the 
presence of eruptions or swellings of any kind. Having remarked these 
various matters during the early part of the examination, he should pro- 
ceed to inspect carefully the whole external surface by touch and sight, 
in order to acquire precise and accurate information upon these points. 

A child who has been healthy from its birth ought to have attained a 
certain average size and development at a certain age. If it be much 
below the average size, if at three months it look like a new-born child, 
or at a year old like one of six months, it is very clear that something has 



28 INTRODUCTORY ESSAY. 

acted to determine such slow and insufficient growth, and it becomes the 
business of the practitioner to discover what the impeding cause has been. 
Not only ought a child to have a certain size and stature, but it should 
also be possessed of a certain degree of embonpoint. A perfectly healthy 
young child, one under four years of age, usually presents a much greater 
fulness and rotundity of the trunk and limbs than does the adult. Its 
tissues are firm and solid, its surface of a cool and pleasant temperature, 
its coloration of a clear and exquisite white, finely tempered with a faint 
rosy tint in a warm atmosphere, or slightly marbled with light bluish spots 
in a colder air. Few marks more certainly indicate a healthful temper of 
the constitution than the clear and exquisitely tinted pink color of the 
palmar and plantar surfaces of the hands and feet of a young child. 
Nothing, indeed, can be more beautiful or perfect in shape or contour than 
the figure of a fine hearty young child ; nothing more pleasing to the eye 
than its delicate but vivid coloring ; and nothing more expressive of the 
fulness of health and vitality than its whole appearance. 

When, therefore, instead of these marks of a pure and active state of 
the health, we meet with stunted growth, emaciation, soft and flaccid tis- 
sues, sallow and dingy tint of the cutaneous surface, pallid or bluish feet 
and hands, weak and listless movements, — how easy the conclusion that 
some jarring agent is at work to hinder and obstruct the machinery of 
life. 

In acute diseases emaciation takes place rapidly, but the tissues still 
retain some degree of elasticity and firmness. In chronic diseases the 
emaciation is of course slower, but it is more complete, so that, in some 
instances, the frame seems to consist merely of the bones wrapped round 
with a dark and unhealthy skin. The tissues beneath the skin, the cell- 
ular, adipose, and muscular, are in great part absorbed, and the skin falls 
into wrinkles and irregularities on the least movement of the child. In 
some cases of disease, and particularly in those of the abdomen, the derm 
loses almost entirely its elasticity, so that when pinched into a fold by the 
fingers, it retains for some time the form that has been given to it. 

The decubitus and gestures of the child ought to be noticed. Healthy 
children are, when awake, almost always in motion. Those who have at- 
tained the habit of walking are tempted to active exercise by their various 
plays and amusements. Infants, though they sleep much more than older 
children, are also, when awake, constantly moving their limbs ; they are 
seldom still. When asleep they rest quietly and comfortably, generally 
upon the side, though often upon the back. How different when the child 
is laboring under disease of any kind. The disposition to movement is gone ; 
the older child insists upon lying on the lap, or in the cradle or bed, and 
the infant is to be soothed of its crying and fretfulness only by rocking 
and fondling in the arms. Instead of the free and spontaneous movements 
of health, we now see only the sudden, impatient, and causeless tossing on 
the bed or lap, or the constant changing of position, with fretting or com- 
plaining, which constitute the agitation of sickness ; or else the slow, lan- 
guid, and hesitating movements of weakness or prostration; or, lastly, 
the stillness and immobility of stupor or of coma. 



DECUBITUS — MUSCULAR MOVEMENTS. 29 

There is nothing peculiar about the decubitus of pneumonia or bron- 
chitis except when there is severe dyspncra, in which case the child, if old 
enough to select its own position, lies high upon the pillows, w^hile those 
who are younger evidently prefer to rest on the lap of the nurse, with the 
trunk and head supported in her arms, and express by crying and agita- 
tion their discomfort and uneasiness when placed in the recumbent position 
on the lap, or in the cradle or crib. We have seen several young children 
affected with severe bronchitis or pneumonia, who have preferred to any 
other i>osition that of being held in the nurse's arms, with the front of the 
chest placed against her chest, and the head hanging over her shoulder. 
When the dyspno?a is so severe as to produce, by slow degrees, a partial 
asphyxia and consequent dulness of perceptivity, the child becomes so- 
porous or comatose, and lies usually upon the back, as in diseases attended 
with prostration of strength. 

In pleurisy and peritonitis the decubitus is usually dorsal, and the child 
dislikes to be moved or nursed often crying violently when touched or dis- 
turbed. 

In intestinal inflammations the young patient is usually excessively rest- 
less at first, and very fretful, unless the attack be grave and threatening, 
when it often lies still for a time from the prostration of strength which 
attends violent attacks, but becomes restless, turns and twists in the bed, 
cries out, and agitates the lower extremities at each evacuation of the 
bowels. 

In the early period of cerebral inflammation there is generally excessive 
restlessness, and great irritability of all the senses and temper, but as the 
case goes on, and passes into the stage of coma, the child becomes still and 
quiet, assuming very often the decubitus called by the French ''en ch'ien 
de fusil;' that is to say, on the side, with the inferior extremities strongly 
flexed, and the arms drawn close to, or crossed over the thorax. This posi- 
tion is especially characteristic of the latter stages of tubercular menin- 
gitis. 

Extreme restlessness, constant tossing upon the bed, or incessant chang- 
ing from the arms to the bed, or from bed to bed, is a very bad sign. We 
have observed it in several different affections ; especially in obstinate pneu- 
monia, in longrcon tinned intestinal disorders, and in the secondary inflam- 
mations of measles and scarlet fever. 

Amongst the gestures most deserving of attention are the sudden starts, 
attended with cries, which indicate the occurrence of some painful sensa- 
tion, as that of colic, of stitch in the side in pneumonia and pleurisy, and 
sometimes of shooting pain in the head. The fre(pient carrying of the 
hand to the head, or to the ear, ought not to pass unnoticed, as this is often 
indicative of headache or earache. So also of the constant application of 
the hand to the mouth, or the introduction of the fingers into tiiat cavity, 
which often occurs when the child is suffering the od(jntalgic pain of den- 
tition. Nor should the physician ever neglect to observe any peculiar and 
especially any automatic movements of the limbs, and particularly of the 
fingers or toes. Nature often heralds the approach of a convulsive seiz- 
ure by certain peculiar muscular movements. The thumbs are drawn into 



30 INTRODUCTORY ESSAY. 

the palms of the hand, and the fingers clasped over them ; or the toes are 
strongly bent towards the sole of the foot, or rigidly extended ; sometimes 
the fingers are for an instant convulsively extended upon the hand and 
drawn widely apart from each other; or lastly, the muscular movements, 
instead of being easy, steady, and natural, are badly co-ordinated ; they 
are irregular, uncertain, and tremulous. This latter character, tremulous- 
ne.s>^ and uncertainty, we have often noticed. 

The occurrence of paralysis will often be unperceived for some length 
of time by an inattentive observer. It is to be discovered by the failure 
of the child to move one limb, whilst the others are more or less agitated, 
or by taking hold of the limb, and comparing the total want of resistance 
in it, with a certain stiffness and opposition to movement almost invari- 
ably present in the healthful condition. 

The state of the cutaneous surface is always important, and ought to be 
carefully and systematically examined. The points most requiring to be 
noted are its temperature, dryness or moisture, coloration, and the presence 
of eruptions or swellings. By the temperature, and dryness or moisture, 
taken in connection with the rate of circulation, we must judge as to the 
existence of fever. The inferences to be drawn from the condition of the 
surface in these respects are the same in children as in adults, and they 
need therefore no particular consideration in this place. 

The coloration of the skin, on the contrary, owing to its great suscepti- 
bility to change in certain affections, becomes, in the diseases of early life, 
of very considerable importance in diagnosis, and deserves therefore some 
special remarks. 

The physician should be aware, in the first place, that the color of a new- 
born infant is some shade of red, varying from a deep brick-red tint, to 
one of a much lighter hue. The red appearance fades aways usually in 
about four or five days, and leaves the surface of a yellowish-white, or in 
some instances of a decidedly yellow color. The yellow color is sometimes 
80 marked as to impose very readily upon an inexperienced person the idea 
that it must depend on an affection of the liver, or, in other words, that it 
conrititutes a true jaundice. In a very large majority of cases, however, 
the conjunctiva retains its natural white tint, the digestive functions go 
on with perfect regularity, there is no fever, and indeed no marks of de- 
cided disorder of the health, so that the icterode hue cannot depend, 
under these circumstances, on any serious lesion of the liver or its append- 
ages, and it is manifestly wrong to regard the case as one of disease, or as 
requiring any treatment. 

Besides the yellow color just described, the cutaneous surface in chil- 
dren, and particularly in those under three or four years of age, very 
often exhibits different shades of a bluish color, which need some atten- 
tion. When the whole skin assumes a decidedly blue tint, the case is one 
of cyanosis or morbus cccruleus, depending on some malformation or dis- 
ease of the heart or lungs. In severe cases of this kind, the blue color 
deepens into a purple or even blackish hue. If this appearance last more 
than a very few days, there can be little doubt that it depends on some 
malformation or disease of the heart. 



ALTERATION OF COLOR. 31 

It is quite coramou to observe iu new-born and very young infants, a 
bluish tint of the hands and feet, and of the parts around the mouth, 
whilst the rest of the body is pale. These appearances depend usually 
on some obstruction to the pulmonary circulation, as that caused by ate- 
lectasis pulmouum, bronchitis, or pneumonia, and they increase, diminish, 
or disapi>ear, according to the course of the causative malady. In older 
chiklren, the blue color of the skin is rarely of any considerable intensity, 
unless the condition has existed from birth, or soon after ; but it is not at 
all UDCoramon to meet with faint, but quite perceptible shades of that color, 
depending on the asphyxiated state which occurs in croup, capillary bron- 
chitis, pneumonia, and sometimes in laryngismus stridulus. It is hardly 
necessiiry to add, that a very slight blueness of the fingers and toes is 
sometimes observed in the cold stage of intermittents. 

Occasionally we meet with an excessive harshness, aridity, and scurvi- 
ness, or with a wrinkled appearance of the skin, especially upon the ab- 
domen and thorax. This symptom, when strongly marked, is usually 
attended with enlargement of the superficial veins of that part, and is 
then very striking even to a careless observer. It accompanies very gen- 
erally the abdominal tuberculosis of children, and should not pass unob- 
served. Though generally indicative of tubercular peritonitis, or of tuber- 
culosis of the mesenteric glands, it is not always so, since in a case that 
occurred to one of us, and in which it was perfectly well marked, a post- 
mortem examination showed it to have been caused by a chronic peritoni- 
tis, resulting from inflammation and suppuration of the mesenteric glands 
entirely independent of tubercular disease. The peritonitis had given 
rise to extensive adhesions amongst the intestines, and the pus had found 
its way by a tortuous sinus between the intestines into the vagina, through 
which it was discharged externally. 

There is one other alteration in the color of the skin which is deserving 
of notice in a practical point of view. It is an excessive pallor, occurring 
sometimes in diseases which obstruct the respiratory function. We have 
been most struck with it in the capillary bronchitis, or suffocative catarrh, 
of youDg children, and in membranous croup. The whole surface assumes 
a dead white hue, which seems to depend on a total want of blood in the 
cutaneous capillaries. The nose is white, the ears become white and di- 
aphanous, and the only relief the eye meets with in gazing upon what 
seems an almost alabaster countenance, is the still pink or bluish lips, the 
dark eyebrows and eyes, and perhaps a somewhat leaden tint of the cir- 
cumference of the mouth and of the forehead. In strongly marked cases 
the whole surface, even of the fingers and toes, exhibits this white or 
blanched appearance. When this condition has lasted for several hours, 
or a day or two, the hands and feet sometimes assume a bluish look, which 
may last until death occurs, or until the attack approaches a favorable 
termination. This condition of the surface, when occurring in cases at- 
tende<l with obstruction of the respiratory function, has always appeared 
to us an indication of imminent danger to the patient; and, indeed, when 
it lasts more than one or two days, it has very generally proved the har- 
binger of death. 



82 INTRODUCTORY ESSAY. 

The clininil examination of the cutaneous surface cannot be considered 
complete until it has been made with reference to the presence of erup- 
tion's, of s^wellings from wdema, of inflammation, tumors, and, lastly, of 
disease;* of the joints. The inquiry in regard to the presence of eruptions 
is a very important one, from the fact that children are particularly liable 
to attacks of the exantheraatous and other eruptive affections. Many 
attacks of sickness, beginning with violent fever and other serious symp- 
toms, which would otherwise remain entirely obscure or unexplained, until 
a much later period from the onset, may be accounted for at an early 
period by a minute examination of the skin. So, in the latter stages of 
long and debilitating maladies, in the disorders which follow scarlatina, 
and in cardiac and hepatic diseases, a proper inspection of the surface will 
reveal cedematous effusions that might, if this search w^ere neglected or 
carelessly prosecuted, remain undiscovered. The same remarks will apply 
to inflammations of the auricular cavities, to the swelling of the joints 
produced by rheumatism, and to some obscure suppurative inflammations 
in the limbs of children. A most instructive example of the necessity of 
this close examination, occurred some years ago in the practice of one of 
us. A healthy male infant, five weeks of age, was seized suddenly with 
most violent fewer, the reaction being not unlike in character that of acute 
rheumatic fever. The only visible disturbance of the health, to explain 
this violent attack, was a certain amount of digestive derangement, and 
for this the patient was treated. After three days of most severe illness, 
with strong tendency to convulsion, and with some stiffening of the lower 
jaw, we were asked to look at the right thigh. It was largely swelled, 
especially in its lower half; it was hard to the touch, and the skin over 
the outside of the limb, just above the knee, had assumed an inflammatory ' 
redness. It was clear that the child had been attacked with an acute in- 
flammation of the deep tissues of the thigh, and that this was now approach- 
ing the surface and becoming visible. Careful inquiry now brought to 
light the fact that the baby, all through the sickness, had cried severely, 
as though in sharp pain, whenever it was moved, and especially when its 
napkins were changed. The distress observed when the napkins were 
being changed, had been ascribed to some smarting from the urine. Had 
the surface of the child been more carefully examined at an early period, 
the swelling of the thigh, and the pain on motion, might, no doubt, have 
been detected then, and the intense febrile reaction, with the nervous 
symptoms, which were thought too great for simple functional disorder of 
the digestive functions, would at once have been explained. 

It is clear, therefore, that in infants and in children under six or even 
eight years of age, the physician must depend, in great measure for in- 
formation as to the nature of the case, on his own unassisted explorations; 
and, knowing this, he should leave nothing neglected that may aid him to 
gauge with accuracy the state of health of the individual before him. 
He should cultivate a habit of minute, systematic, and patient investiga- 
tion, since by accustoming himself to such a method in his daily walks, he 
will assuredly attain, in the end, a tact and sagacity that will not often be 
at fault. 



PULSE. 33 

The Pulse. — The pulse of the chikl, iii order to be judged of to auy 
real advantage, must be examined during the state of quiet, and, if pos- 
sible, it should be felt whilst the child is either asleep or dozing. During 
the wakins: state a young infant is in such constant motion, that it is very 
difficult to perceive the pulsations of the radial artery, and impossible to 
judge of their force or volume, in consequence of the rising and falling of 
the flexor tendons of the forearm, and because, also, of the natural soft- 
ness and delicacy of the pulse at that age. In older children, the moral 
disturbance occasioned by the visit of the physician in most instances, and 
the irritability and nervousness accompanying the sickness, will either 
'^ause the patient to resist the attempt to touch the arm, or else produce 
-o great an effect upon the rate and force of the circulation, as to render 
very uncertain and unsatisfactory any conclusions to be drawn from the 
examination. If possible, therefore, the circulation should be examined 
during sleep. If this be impracticable, the child ought, when still nurs- 
ing, to be put to the breast, or, when weaned, it ought to be quieted by 
soothing treatment, by toys, or by the promise of a toy. 

It is essential that we should know what is the average of the healthy 
pulsations of the child, in order to obtain a standard of comparison by 
which to judge of any departure from that average in disease. Observers 
have varied not a little in the results at which they have arrived by their 
examinations upon this point. By selecting those, however, which appear 
to have been made with the greatest care, and under the most favorable 
circumstances, we shall, doubtless, obtain an average entirely worthy of 
confidence. It will be necessary, also, to obtain averages for different pe- 
rijHJs of childhood, since the rate of the circulation varies to a very great 
extent at different ages. We shall, therefore, give the rate of the circula- 
tion for new-born children (one to ten days old), for the period from four 
: . Mthft to six years, for that from six to nine years, and for those from 
; .. to twelve, and from twelve to fifteen years of age. 

The average rate of the circulation in very young infants, is from one 
hundred and one to one hundred and two in the minute, the former being 
the result obtained by M. Billard in children from one to ten days old, 
n- Tiearly a> it f-an he gained from his statements, and the latter the one 
liiaiiicHl by M. Roger, in infants from one to seven days old {l)r In Tnn- 
perature chez les EnfaiUs, Paris, 1844). The physician ought, however, to 
be aware of the fact that, though the above is the average rate of the cir- 
culation at the age mentione<l, the pulse may range very much above or 
^• \s that average, without necessarily indicating a morbid state of the 
ii-ulth. Thus, though the average frequency in forty children, from one 
to ten days old, observed by M. Billard, was one hundred and one, it was 
If^s than cifrhty in eighteen, whilst in iourtt^en it was between one hundred 
and one hundre<l and twenty-five, and in nix between one hundred and 
thirty and one hundred and eighty. All these children, he a-ssures us, 
prej»enled every mark of good health. 

The average frequency of the pulse during the first year may be statefi 
at about one hundred and fifteen ; at lea«t such is the result obtaincrl by 
us from an examination of seven ol«*ervations by M. Roger of children 



34 INTRODUCTORY ESSAY. 

from four to uine mouths old. This result, it will be observed, shows that 
the pulse is not so frequent during the first fe^v days after birth, as it be- 
comes at a somewhat later period, which, moreover, agrees with a previous 
statement to the same effect made by M. Valleix. This latter author is 
of the opinion that at seven months of age the pulse is much more fre- 
quent than some days after birth, and that it afterAvards falls gradually as 
the child advances in years. 

We are not acquainted with any observations upon the rate of the cir- 
culation during the second year of life, except those of M. Trousseau, who, 
according to M. Bouchut {Manuel Prat, des Mai. des Nouv.-Nes, p. 133, 
Paris, 1845), gives as the average between one year and twenty-one months, 
one hundred and eighteen. 

M. Becquerel (Traite Theorique et Prat, des Mai. des Enfants, Paris, 
1842), gives us the result of his observations upon thirty children, be- 
tween two and six years of age, during sleep and in the waking state. 
During sleep the average was seventy-six ; in the waking state it was 
ninety-two. 

Between six and nine years of age, the same observer found the average 
during sleep to be from seventy-three to seventy-four, whilst in the waking 
state it was ninety. Between nine and twelve years, the average was, 
during sleep, seventy-two, in the waking state, eighty. Between twelve 
and fifteen years the rate was seventy whilst the children were asleep, and 
seventy-two when awake. Roger gives seventy-seven as the average be- 
tween six and fourteen years. 

One very striking fact attracts our attention in the above statements : 
the much greater difference between the rate of the circulation during 
sleep and during the waking state, in very young children, than in those 
who are somewhat older. Thus, whilst there is a difference of seventeen 
pulsations in the minute, in the rate of the circulation during sleep and 
in those who are awake, between the ages of two and six years, the differ- 
ence under the two conditions mentioned, amounts to only two pulsations 
in the minute in children that have reached the age of between twelve 
and fifteen years. 

The circulation is somewhat more rapid in girls than boys. This differ- 
ence should be borne in mind, but as it amounts to only about five beats 
in the minute, it is insufficient to be of any very decided value in diagnosis 
or prognosis. 

After these specifications as to the rate of the circulation in children, 
we shall pass on to some general remarks upon the method of the exami- 
nation of the pulse, and upon some other of its important characters. 

M. Bouchut (loc. cit, p. 129) remarks that in infants at the breast " the 
palpation of the pulse is almost impossible. It may be counted, but its 
force, feebleness, size and hardness, can scarcely be appreciated ; the inter- 
mittent character is the only phenomenon upon which no doubt need rest ; 
it is, moreover, the only one of any value." These opinions of M. Bouchut, 
though true in some degree, are much too strongly stated, for we are quite 
sure that it is very easy to detect great differences in the force, size, and 
tension of the pulse of the same child in health and in disease, and of 



EXAMINATION OF THE HEART. 35 

different children laboring under different diseased conditions. These dif- 
ferences can be detected by careful observation from a very early age, and 
after two months may be readily recognized, ^vhen the variation from the 
state of health is at all considerable. 

The intermittence of the pulse above alluded to, should rather be ex- 
pressed by the word inrgularitij, since the pulse is not properly intermit- 
tent, but merely irregular in its rhythm. This is quite a common feature 
in the pulse of children, and, be it noted, is much more frequently met 
with during sleep than in the waking state. M. Becquerel met with irreg- 
ularity of the pulse in twenty-four of one hundred and fifty children ex- 
amined during the waking state, and in fifty-five of one hundred and fifty 
during sleep. It is clear, therefore, that mere irregularity of the circula- 
tion, independently of other symptoms, is not a sign of disease, since it 
was present in one-sixth of those awake, and in a little more than a third 
of those asleep. It should be observed, too, that the greatest irregularity 
exists when the pulse is lowest (in sleep). The chief practical bearing of 
this fact is that we should be careful not to lay too much stress upon the 
slowness and irregularity of the pulse, as signs of tubercular disease of the 
cerebral meninges, unless they are observed during the waking state, and 
in connection with other symptoms ; particularly with vomiting, constipa- 
tion, and severe headache. 

Another very important characteristic of the circulation of the child, 
is its extreme irritability, which causes its rate to vary to an extraordinary 
degree, even in perfect health. This is the more marked in proportion as 
the child is younger. The slightest disturbance, whether moral or phys- 
ical, will cause the pulse to rise in a young child from one hundred or one 
hundred and fifteen, to one hundred and twenty, one hundred and thirty, 
or even one hundred and fifty. From this circumstance may be drawn 
the inference also, that the pulse should always be examined, as before 
stated, during sleep, or during profound quiet. 

There is still another reason which makes it necessary to touch the pulse 
during sleep or profound quiet. This is, that when the child is agitated, 
it becomes literally impossible, in consequence of the contractions of the 
flexor tendons of the arm, and of the movements of pronation and supi- 
nation, to judge with accuracy the various qualities of the arterial action. 

Examination of the Heart. — The examination of the heart by aus- 
cultation and percussion ought, and, to be of essential aid in diagnosis, 
must be performed while the child is still and quiet. It is best made dur- 
ing sleep, especially in infants ; when this is impossible, it can be performed 
with great advantage during the state of quiet that follows nursing, or 
during that which may often be procured by soothing management, or by 
taking advantage of the fotftluess that infants show for a strong light, the 
view of which will generally suffice to occupy and keep them still. 

The sounds of the heart present the same general characters in the child 
as in the adult. They are, of course, more feeble and more rapid ; condi- 
tions which make it difficult, in the young infant, to perceive and aj^pre- 
ciate any minute change from the healthful sounds. After tlie age of one 
and two years, however, when the circulation has become slower and more 



36 INTRODUCTORY ESSAY. 

steady, the signs yielded by the physical examinatioD of the heart become 
much more valuable aud positive; so much so, indeed, as to yield results 
almost as important as in the adult. The first sound is almost always 
duller than the second. They succeed each other commonly with perfect 
regularity, and have the same interval between each in the same child. 
The cardiac sounds are readily heard by placing the ear over the prsecor- 
dial region. The extent of surface over which they may be heard will 
depend on several conditions : particularly the state of quiet or agitation 
of the child, the presence or absence of fever, the state of the lung as to 
its consistence (constituting it a better or a worse conducting medium of 
sounds), and the condition of the heart itself as to health or disease. 

In a healthy child, who is undisturbed by any cause of irritation, and 
particularly in one sleeping, the sounds are distinctly audible over the 
whole prsecordial region and under the left clavicle. In many subjects 
they can be heard over the whole front of the thorax, but become, of course, 
feebler in proportion as we recede from the prsecordial region. Usually 
they are heard quite as distinctly under the right clavicle as over the nip- 
ple of that side, in consequence, no doubt, of their transmission in an 
upward direction by the aorta. They are never heard over the posterior 
walls of the chest in children in perfect health, and whose circulation is 
entirely undisturbed. In those who are awake and agitated, and in those 
who have been making severe muscular exertions, the cardiac sounds are 
very loudly audible over the whole front of the thorax, and even through 
to the back of the chest. 

When the lungs are indurated by inflammation, as in pneumonia, they 
transmit with great distinctness, from having become better conducting 
media, the cardiac sounds to the back. This circumstance sometimes be- 
comes a valuable aid in the diagnosis of pneumonia. We have been ena- 
bled to satisfy ourselves of the existence of pneumonia in the lower lobe 
of the right lung, in a doubtful case, from the fact that the sounds of the 
heart were much more clear and distinct over the right inferior, than over 
the left inferior dorsal region. 

The prsecordial region is decidedly less sonorous on percussion than the 
parts of the thorax directly over the lungs. This diminution of sound is 
distinct enough to be evident to any ordinary ear, but it rarely amounts 
to absolute flatness. The region exhibiting this dulness of sound is the 
same in position as in the older person. It occupies the space correspond- 
ing to the cartilages of the fifth, sixth, and seventh ribs, and is situated, 
therefore, between the left nipple and the left edge of the sternum. Its 
measurements, as given by MM. Rilliet and Barthez, are one and a half 
to three inches in a transverse, by one and a half to two and a half in a 
vertical direction. The region of dulness is flescribed by those observers 
as being represented by a circle or ellipse, the transverse diameter of which 
extends from the nipple to the sternum, or more rarely, towards the xiphoid 
cartilage. In children over six years old, the nipple sometimes lies above 
the middle line of this space. 

THERMOMii:TRic OBSERVATIONS IN CHILDREN. — As an indication of the 
intensity and character of the disease in febrile attacks, we have seen that 



THERMOMETRIC OBSERVATIONS IN CHILDREN. 



37 



the frequency of the pulse is little to be depended on. Dr. Forster (Jour. 
f. Kind., July and August, 18G2, in Xew Syd. Soc. Year-Book; 1862, p. 413), 
who has made an extensive series of observations upon this subject asserts 
that variations in the temperature of the body ofter far more certain indi- 
cations. The instrument used was a Reaumur's thermometer, eight and a 
half inches long, in which slight variations are easily appreciable. The 
bulb was placed in the axilla. 

The results given are those of observations upon healthy children, during 
the first few days of life. 

A constant lowering of the temperature of the bod}' takes place after 
birth, which reaches its maximum, 28.97° R., on an average within the 
first two hours after birth. 

Hours after Birth. Averag*^ Tt'mp. (R.) Minimum Temp. (R.) 

i— 2, 28.97 28.2 

2—6, 29.12 28.1 

6—10, 2949 28.7 

10—15, 29 53 29 

15—20, 29 31 28 8 

20—25, 30.04 29.7 

25—30 29.9 29.7 

30—36, 30 07 29 7 

36—42, 80 04 29.4 

42—48 29.86 29.3 



A subsequent elevation always occurs. The average time at which the 
highest temperature was observed, was from thirty to thirty-six hours after 
birth, at which time the average was 30.07° R.: maximum 30.4° R., mini- 
mum 29.7° R. 

This elevation was noticed equally when the infant had and had not 
taken food. 

During the first nine days of life, the temperature was observed as 
follows: 

Day*. 

1 -u, 

2 — 2i. 
2i— 3. 

3 —3*, 
3i-4, 
4-4i, 
4i-5, 
6 -5i, 
5J-6, 
6 -6i, 
6i-T, 

7i-8, 
8 -84, 
8J-9, 



We thu.s see that fi 
the highest tempera 









No. of 


Maximum (R.) 


Minimum (R.) 


Average fR.) 


Observations 


. 30.4 


29.7 


30 01 


22 


. 30.5 


29.3 


29.93 


16 


. 30.4 


29.3 


29.87 


28 


. 30.3 


29 2 


29.74 


16 


. 30.3 


20.3 


29.76 


27 


. 30.2 


290 


29.68 


17 


. 30.4 


29 2 


29 68 


25 


. ?>^i.Z 


29.2 


29 72 


18 


. 30.4 


29.2 


29 82 


23 


. 80.5 


29.8 


29 81 


16 


. 306 


29.4 


29.83 


23 


. 30.3 


29.1 


29 75 


17 


. 30.4 


29.3 


29.82 


22 


. 30.4 


29.0 


29.72 


11 


. 30.0 


29.4 


29 70 


8 


. 29.9 


29 6 


29.75 


2 



era the thirtieth to the thirty-sixth hour after birth 
ure is observed. Then a fall takes place, which 



38 INTRODUCTORY ESSAY. 

reaches its maximum at four days after birth (average maximum 29.68° 
R.). Again, between the fifth and eighth days, a new elevation of tem- 
perature occurs ; but this new elevation is less in degree than that pre- 
viously noted. The average maximum was 29.83" R. Some differences 
were found in the results, according as the children, were large and heavy, 
or the reverse. Large and well-developed children had a slightly higher 
temperature than those less robust. 

Thus the average temperature in the early part of the day was, in 
children weighing eight pounds and upwards, 29.84° R.; but, in children 
weighing less than this, the average was 29.65° R. The evening observa- 
tions, again, gave an average for the heavy children of 29.94°; for the 
others, of 29.77° R. Resj^ecting the temperature at different times of the 
day', observations showed that, from the second to the ninth day, there was 
an average elevation of temperature, from morning to evening, amounting 
to .11° R. ; the average morning temperature being 29.75° R. ; the average 
evening temperature, 29.86° R. 

This interesting subject has been further examined in regard to older 
children, by Mr. Finlayson (^Proc. of Manchester Med. Soc., in Brit. Med. 
Jour., Jan. 16, 1869, p. 59). 

His results are based on two hundred and eighty-one observations on 
eighteen different children, of ages varying from twenty months to ten 
and a half years, a ud are as follows : 

1. The daily range of temperature is greater in the healthy child than 
that recorded in healthy adults — amounting to 2° F. 

2. There is invariably a fall of temperature in the evening, amounting 
to 1, 2, or 3 degrees. 

3. This fall may take place before sleep begins. 

4. The greatest fall is usually between 7 and 9 p.m. (at least under the 
conditions of life in hospital). 

5. The minimum temperature is usually observed at or before 2 a.m. 

6. Between 2 and 4 a.m. the temperature usually begins to rise, such rise 
being independent of food being taken. 

7. The fluctuations between breakfast and tea-time, are usually trifling 
in amount. 

8. There seems to be no very definite relationship between the frequency 
of the pulse and respirations, and the amount of temperature ; the former 
being subject to many disturbing influences. 

RespiPwAtion ; its Rate and General Characters. — The respira- 
tion, like the pulse, to be examined with any advantage to the explorer, 
must be investigated whilst the child is still and quiet. In the young in- 
fant it should be done during sleep, as it is only then that we can find the 
breathing uninfluenced by disturbing causes other than those connected 
with deranged health. In the older child, the play of whose functions is 
more steady and regular, and less readily jarred by trivial causes, this part 
of the clinical exploration may be made during the waking state ; but, still, 
it must be done whilst the patient is quiet and tranquil, else the results 
obtained will necessarily be less certain and reliable than under the oppo- 
site state of things. 



RESPIRATION, ITS RATE, ETC. 39 

The respiration ought always to be counted bv tlie watch, if possible, 
especially bv the young practitioner. This is the only mode in which a 
perfectly accurate idea of the frequency of the respiration is to be obtained. 
It sometimes happens that a greatly increased rate of the breathing will 
pass unnoticed by the physician, from the fact that it continues to be reg- 
ular and without effort. We have known children to breathe eighty times 
in the minute, without presenting any appearance of labor or effort in the 
act; without cough, and without the least wheezing or sound to be heard 
at a short distance from the patient. Under these circumstances, the great 
rapidity of the respiration might very well pass unnoticed, especially by 
inexperienced practitionei^ ; and, be it remarked, this would be particularly 
apt to happen were the attention of the physician addressed to some other 
part of the economy than the thorax, as the seat of the sickness. For 
instance, in latent pneumonia, when this simulates meningitis, or when it 
is conjoined with gastro-iutestinal symptoms, the failure to note a greatly 
increased rate of the breathing might very well occur. In many cases of 
secondary pneumonia, it might also take place. In children, who have 
been long sick with diseases that debilitate and impoverish the health, a 
sudden aggravation of the symptoms dependent on collapse of the lung, 
might be misunderstood and falsely explained, for the want of this pre- 
caution. It is therefore a good and useful rule, for the young practitioner 
always to count the respiration, when he has to do with a case presenting 
the least obscurity of diagnosis, since this simple habit may guide him to 
the real seat of disease, which else he might mistake. 

The rate of the respiration in children is very different at different ages, a 
circumstance that should always be recollected in the examination of their 
diseases. The average frequency of the breathing in new-born children and 
during the first week of life, is thirty-nine, according to M. Roger. It may 
rise, however, upon very slight disturbances, to fifty, sixty, or even eighty, 
while it is not at all unusual to find it at twenty-five or thirty in perfectly 
healthy infants during sleep. Between the ages of two months and two 
years the average is about thirty-five. Between two and six years, the 
average is eighteen during sleep and twenty-three during the waking state ; 
from six to twelve years, the average during sleep is eighteen, and in the 
waking state twenty-three; from twelve to fifteen years, it is eigliteen in 
the former, and in the latter twenty. It wmH be observed, therefore, that 
after the age of two years, the rate of the respiration is nearly the same 
throughout the remainder of the period of childhood ; it changes so little, 
indeed, that the same average will answer for all practical purposes through- 
out that period. 

The other characters of the respiration require some attention on the 
part of the practitioner. In the first place, the diaphragm plays a more 
important part in the process in the child than in tlie adult. In the young 
infant, indeed, the function is carried on almost wholly by the action of 
that muscle, so that the respiration is correctly described by the technical 
term of abdominal. The walls of the chest are almost motionless. On 
this account the rate and character."* of the breathing can be best studied 
in young children, by examining the abdomen, the movements of which 



40 INTRODUCTORY ESSAY. 

being strong and marked, are much more easily seized by the eye than are 
thoso of the thorax. 

During })eriect quiescence, and especially during sleep, the breathing of 
a young child is soft, regular, though less so than in the adult, and per- 
fectly noiseless ; it is necessary to place the ear close to the face or chest 
of tlie child, and to listen attentively, in order to hear it. It the young 
child, and especially the young infant, the breathing is, in the waking 
state, very different from that of the adult. It is short, irregular, uneven, 
and marked by occasional pauses, followed by a hurry and precipitation 
of the movements. These peculiarities in the respiration of the infant 
appear to depend on the weakness and imperfect action of the muscular 
apparatus at that early age, which causes the various movements of the 
body to be hesitating and uncertain, and without that steadiness and even- 
ness which arc characteristic of matured strength. After the age of two 
years, these irregular and tumultuous movements cease, and the breathing 
becomes more regular and even, like that of adults. 

In the inflammatory affections of the lungs, — pneumonia, bronchitis, 
and pleurisy, — the respiration is almost invariably accelerated. In exten- 
sive pneumonia, and in capillary bronchitis, it becomes very rapid, rising 
to eighty or one hundred in the minute. In pleurisy and simple ordinary 
bnHichitis, it seldom becomes so frequent, not exceeding, usually, forty or 
fifty. In severe pneumonia, the rhythm of the movement sometimes be- 
comes inverted : the pause occurs at the termination of the inspiration 
instead of the expiration. The patient makes first a violent and labored 
expiration, bringing into a kind of convulsive action all the expiratory 
muscles of respiration; instantly after the expiration follows a rapid and 
full inspiration; then occurs a momentary pause, and again the respira- 
tory act begins with the labored expiratory effort. This kind of respiration 
is a very unfavorable symptom, as it is indicative of a most dangerous 
oppression. It is particularly apt to occur in infants, and very young chil- 
dren. It has been called expiratory respiration. 

Tiie respiration, though almost invariably accelerated in pulmonary in- 
flammations, sometimes retains its normal rate, or even falls below that 
rate. This occurs, we believe, only under one condition of things : when 
the forces of the constitution have been sapped by previous disease, or ex- 
hausted by the long continuance of the thoracic inflammation. It is there- 
fore met with in cases of secondary inflammations, and in those of the 
chronic form. 

The respiration is very much increased in frequency as a general rule 
in Atelectasis Pulmonum, or collapse of the lungs. When, therefore, a 
young child who has been exposed to the causes of this disease (feeble- 
ness at birth, exhausting disease, or debilitating hygienic conditions), is 
su<ldenly seized with hurried respiration, slight cough, paleness or blueness, 
with coldness of the cutaneous surface, and in whom there are but few and 
unimportant physical signs of pulmonary disease, there is very good reason 
for supposing that some portion or portions of the lungs have become col- 
laj)sed, or, in other words, have ceased to admit air. 

The respiration often lends some assistance in the diagnosis of cerebral 



AUSCULTATION AND PERCUSSION OF LUNGS. 41 

affections. In acute meningitis, accompanied by violent febrile reaction, 
it is more frequent than natural, but often irregular. When the early 
stage pjii^es into the stage of coma, the breathing becomes slow and ir- 
regular. In tubercular meningitis it is seldom increased in frequency 
except for a day or two before death, whilst in the middle period of the 
disorder, it is either continued at it* normal rate, or becomes slower. 
During that period, also, it is almost always extremely irregular, and is 
interrupted by long and mournful sighs, which, to the ear of the experi- 
enced physician, who hears in them the almost certain prognostic of ap- 
proaching death, have an inexpressibly touching sound, increased tenfold 
by the consciousness of his utter inability to control the fatal tendency of 
the malady. 

There is a peculiarity of the respiration which occurs in collapse of the 
lung, and also in cases of membranous croup, which ought not to be passed 
by unnoiiceil. It is, that during the inspiratory effort, the ribs move in- 
wards and backwards towards the mesial line of the trunk, instead of out- 
wards as in normal respiration ; and at the same time there may be reces- 
sion of the lower part of the sternum, so that a more or less deep sulcus 
is produced around the base of the thorax. This peculiarity is readily 
explained, a^ shown by Rees and Jenner, by reference to the normal rela- 
tion which exists between the current of inspired air, the expansion of the 
lungs, the descent of the diaphragm, and the firmness and resistance of 
the thoracic walls. If this relation be disturbed in any way, the phe- 
nomena we are now considering may be produced. Thus if the diaphragm 
contract suddenly and violently, the lungs cannot expand with sufficient 
rapidity, and in order to prevent the occurrence of a vacuum, the tho- 
racic walls must yield to the external atmospheric pressure at their least 
resisting part, which is, under normal conditions, at the base of the chest. 
The same result must occur, also, when the diaphragm contracts with 
only normal force, but when the calibre of the larynx is much narrowed, 
or again, when a considerable portion of lung-tissue is collapsed. In the 
article on ricket.**, an affection in which the firmness of the chest-walls is 
much diminished, a full account will be found of the masterly manner in 
which Jenner has applied the above principles to the explanation of the 
deformities of the thorax so characteristic of that disease. 

Ai's< TLFATioN AND Perci's.«ion OF THK LuNCJS. — This portion of the 
examination of the sick child ought to be performed, if possible, whilst 
the patient is still and quiet. Unfortunately, however, it happens in a 
large majority of cases that the di.sturbance of position necessary to effect 
the exploration, and the presence of the physician, together with the irri- 
tability of nerves and temper occasioned by sickness, almost always cause 
more or less resi.«*tance on the part of the child, and produce violent scream- 
ing and struggling. In young infants we have to contend only against the 
instinctive resistance to any physical disturbance naturally attendant upon 
sickness and suffering. In older children, who have learned to distinguish 
between familiar and strange faces, and in whom the will has begun to act, 
there is added to the instinctive resistance of the infant an opposition of 
the moat strenuous and annoying kind, founded upon the natural fear of a 



42 INTRODUCTORY ESSAY. 

stranger, and upon a mental determination not to be interfered with or 
incommoded by the movements and changes of position necessary for a 
careful examination. 

•For these reasons, the physical exploration of the chest in young sub- 
jects is often to be accomplished only with great difficulty, and in the 
midst of the most violent screaming, struggling, and contention. It is 
clearly important to avoid these obstacles if possible. This can only be 
done by the employment, on the part of the attendants and physician, of 
the most soothing, gentle, and patient management ; and in this way, let 
it be remarked, it can be done in a large majority of cases. The posses- 
sion by the physician of a quiet and yet decided manner, the power to 
interest and attract the child by entering with active sympathy into its 
little amusements and pursuits, the skill to engage its attention by the ex- 
hibition of some book or toy, or the mere influence he may exert to calm 
its terror of excited irritability, by a soothing voice and gentle persuasion, 
will, in many instances, overcome any resistance offered to the examina- 
tion by children over two years of age. Nevertheless, in very young 
children, and in not a few that are older, no gentle means whatever will 
overcome opposition. Here the exploration must be made in the midst of 
struggles and cries, and though the results obtained will be less clear and 
positive than when the child is reasonable and obedient, a great deal of 
most valuable information can be acquired by a quick and dexterous 
practitioner. The percussion can be made in the short intervals between 
the cries, or even during their continuance, and by placing the ear close 
to the finger by which it is performed, the sounds elicited can be very 
well heard and judged. The auscultation is more uncertain ; but, by 
watching intently the long and deep inspirations which immediately pre- 
cede the violent cries, the presence or absence of rales, and their charac- 
ters, the degree of freedom with which the air enters the lung, and the 
existence or non-existence of bronchial respiration, can, after some expe- 
rience, be ascertained and commented upon, so as to give considerable 
certainty to the diagnosis. 

The particular position in which to place the child, during the exami- 
nation, is of some importance. After the age of three and four years the 
position may be the same as that selected for the adult, if only the 
patient be reasonable and tractable. When, on the contrary, the child 
resists, it should be taken on the lap of the mother or nurse, or else held 
in the arms, with the head inclined over one shoulder, while its back is 
presented to the practitioner. Infants within the year may sometimes 
be examined whilst engaged in the act of sucking ; but this is inconve- 
nient, both from the constrained position, and from the cii'cumstance 
that the inspirations are short and imperfect during the act. The French 
authors recommend that the very young infant should be laid, with its 
face downwards, across the hand of the practitioner, who is then to ap- 
proach the back of the chest to his ear. We have found either one of 
the three following positions most convenient, as the case may be : the 
infant laid across the lap of the mother, with its face downwards, and the 
head hanging a little over one knee ; held in the arms, with the front of 



EXAMINATION OF THE LUNGS. 43 

its bodv placed agaiust the mother's chest, and the head lying over her 
shoulder; or, lastly, a favorite position of ours, placed in a sitting posture 
upon the lap, supported by one hand in front, and by the other holding 
the occipital portion of the head. 

Auscultation should always be performed before percussion, because 
the latter generally alarms or annoys the child, and occasions crying, 
which of course would interfere more or less with the auscultation, were 
this performed after percussion. The auscultation should be made with 
the ear rather than the stethoscope, for the reason that the instrument 
terrifies the child,- and also because it cannot, when the child resists and 
struggles, be kept in contact with the chest. jNIoreover, the instrument 
is unnecessary, except for the examination of the upper portions of the 
thorax in front, and it had better, therefore, be dispensed with. 

Percussion is best made in children by using a finger of the left hand 
as the pleximeter, and by striking with one finger of the right. One 
finger is quite sufliicient to elicit all necessary sound in young subjects. 
The strokes should be light and distinct, consisting of short, quick, and 
gentle taps. 

To perform auscultation and percussion with success, the surface ought 
to be quite uncovered. The habit of examining the thorax through one 
or several thicknesses of clothing, which some persons fall into, is a most 
careless one, and cannot but lead to uncertain and erroneous results. 

As a general rule, it is suflicient, in young children, to examine the 
posterior portion of the thorax. Doubtless it is more accurate and artis- 
tieal tx> explore the whole chest, and this ought to be done in all obscure 
cases. But when the child is sick and suffering, when it is irritated and 
exasperated by the presence of a stranger, or by coercion, and still more, 
when it is weak and exhausted by long or violent illness, it becomes of 
the greatest importance to shorten, as much as possible, the time occupied 
in the examination. For these reasons, it is well to be aware of the fixct 
that, in nearly all inflammatory diseases of the lungs, the morbid changes 
aff*ect first and most .severely the posterior surfaces of those organs. Tliis 
is thought to depend on the fact that the child passes so large a portion 
of it-J time in the recumbent position as to cause the fluids of the body to 
gravitate towards the df'i)endent parts of the lungs, and thus to deter- 
mine the beginnings of inflammatory action in that direction. Certain 
it Is, be the explanation what it may, that it is rare to find the anterior 
surface of the lungs afl^ected either with bronchitis, pneumonia, or pleu- 
risy, the posterior surface remaining healthy. When, therefore, upon 
auscultation and percussion, no signs of disease are met with over the 
dorsum of the thorax, we may feel pretty well satisfied that the lungs are 
healthy. Nevertheless, in all doubtful cases, the examination ought to 
be extended to the whole chest, in order to make what was, before this 
ha-s been done, only a strong probability, a certainty. Whenever, also, 
it is important to ascertain the precise amount of disease in any serious 
or long-continued sickness, the front as well as the back part of the chest 
must be examined. 

The rej*piratonj sounds are not of the same character precisely in the 



child as in the adult, and of this the physician ought to be aware. In 
children the vesicular murmur is stronger than in the adult, so that it as- 
sumes somewhat of a blowing or bronchial sound. It was in consequence 
of this peculiarity that Laennec gave it the name of puerile respiration, 
which, though a mark of health in early life, is, at the period of matu- 
rity, an indication of a morbid change in some portion of the pulmonary 
parenchyma. It ought to be remarked, however, that in infants under 
two, and particularly in those under one year, the vesicular murmur is, 
in ordinary respiration, weaker than in adults ; owing, no doubt, to the 
fact that the inspirations are short and imperfect, not distending the lungs 
to their full capacity. When, however, from any cause, a sigh, a sudden 
disturbance, or the act of crying, a full and complete inspiration takes 
place, so as to dilate thoroughly the pulmonary structure, the murmur 
becomes at once loud and strong, or, in other words, puerile, as in older 
children. 

The murmurs of inspiration and expiration bear the same relation to 
each other as in the adult ; the expiration being much shorter and feebler 
than the inspiration, though, at the same time, it, like the inspiration, is 
louder than in the adult. In some instances, however, and especially over 
the posterior, inferior, and lateral regions of the thorax, no sound whatever 
is heard during the accomplishment of the expiration. This absence of 
sound during expiration is the more apt to be met with in proportion as 
the child is younger. 

When a young child is made to breathe forcibly and rapidly, the res- 
piratory sounds assume certain characters, even in perfect health, which 
might mislead an inexperienced observer. The inspiration is short, loud, 
and hard, so as to assume somewhat of a blowing character, resembling 
not a little the sound of bronchial respiration. At the same time, the ex- 
piration becomes louder also, and longer, which two circumstances, rude 
or even blowing inspiration, with loud and somewhat prolonged expira- 
tion, may very well deceive a young or careless practitioner. 

The respiration is most clear and characteristic over the anterior lateral, 
and posterior inferior regions of the thorax. Over the origin of the larger 
bronchia, that is to say, in the interscapular region, the respiration is very 
strong, so as to resemble very closely bronchial blowing. Here, also, the 
expiration is often very marked; it is sometimes heard as long, or even 
longer than the inspiration. Over the scapulas, the sound of respiration 
is always feebler than elsewhere, except in the pr?ecordial region from the 
interposition of the scapulas and of thick muscles between the ear and the 
lung. 

Percussion yields a much louder and more sonorous sound in children 
over two years of age than in adults, — a circumstance always occurring 
coincidently with the presence of puerile respiration, and dependent on 
the fact that the function of respiration is, at that age, very active, and 
the lungs therefore filled to their utmost capacity with air. In infants 
under two years of age, the sonorousness varies to a considerable extent in 
the same child. When the respiration is, as it usually is, gentle and easy, 
the inspirations being rather feeble and incomplete, the amount of air con- 



EXAMINATION OF THE ABDOMEN. 45 

tained in the lungs will be somewhat deficient in comparison with what 
their cells might contain, and the sound yielded upon percussion will neces- 
sarily be rather dull and insonorous. When, on the contrary, the respira- 
tory process is quick, active, and energetic, from any cause, so as to give 
rise to the auscultatory phenomenon called puerile respiration, the percus- 
sion will be loudly sonorous, as it is in the later periods of childhood, owing 
to the thorough dilatation of all the air-cells, and the consequent presence 
in the thoracic cavity of a large amount of air. 

The sonorousness of the thorax is different in different parts in children, 
as in adults. In front, the percussion is most sonorous from just beneath 
the clavicle on the right side down to one or two inches below the nipple, 
where it gradually becomes dull, owing to the position of the liver. On 
the left side the sonorousness is modified by the presence of the heart in 
the manner already mentioned. Below the precordial region we again 
have pulmonary resonance down to the sixth or seventh ribs, below which 
is heard the tympanitic sound of the stomach. 

Behind, the sound is very dull above the spine of the scapula, and con- 
siderably so over the scapula beneath its spine. Over the interscapular 
space it is clear and strong, and more so in the lower than in the upper 
half. Beneath the inferior angle of the scapula, likewise, it is clear and 
full, until we approach the inferior margin of the thorax, where it is dulled, 
even above the lower edge of the lungs, by the presence beneath of the 
liver on one side and of the spleen on the other. Over the right side the 
dulnesd begins a little higher than over the left, in consequence of the 
greater bulk of the liver than of the spleen. 

The lateral regions are very resonant in their upper portions, but become 
dull as we approach the liver on the right side and the spleen on the left. 
On the left side the pulmonary sound is often entirely eclipsed by a tym- 
panitic rcMjnance occasioned by the presence of gas in the stomach. 

In practicing percussion in children it is necessary to strike gently, be- 
caus(\ from the great natural sonorousness of the chest in early life, any 
con>iderable force would bring out so much sound as to prevent the recog- 
nition of a degree of dulness which might readily be perceived by the use 
of more gentle blows. It is necessary always to compare the two sides to- 
gether, as in adults, since this often leads to the detection of a degree of 
imflaired resonance which might l>e otherwi-ne inappreciable. Yet, and 
the physician ought to be well aware of this, the comparison of the two 
sides is not quite so useful in young as in mature subjects, because of the 
fact that the diseases in which the differential comparison is most impor- 
tant, pneumonia and pleurisy, are more frequently double than in adults. 
It becomes, for the same reason, very important to compare the upper and 
lower portions of the thorax behind, since we may assure ourselves of the 
existence of dulness below, of which we were before doubtful, by the fact 
that the sound is less sonf»rous in that region than above; which is, as 
already stated, the yery opposite of the healthy condition. 

ExA.MiNATioN OF THE Abdomen. — It is ofteo Very important to ascer- 
tain, by palpation, the form, size, and degree of tension of the abdomen, 
the preaence or absence of effusions within its cavity, and the condition of 



46 INTRODUCTORY ESSAY. 



the organs which it contains ; to learn by percussion the degree of reso- 
nance which it affords ; and, lastly, to find by pressure whether it be un- 
naturally tender to the touch or not. By a careful inquiry into these 
various points, and a proper comparison between them and the rational 
symptoms presented by the patient, we shall be able to discover the exis- 
tence of tumors, of hypertrophied organs, of unusual developments of gas 
in the intestines, of dropsical effusions, of enlarged and hardened mesenteric 
glands, of gurgling, and of soreness on pressure caused by inflammation of 
some of the contents of the cavity. The examination should be made, if 
possible, whilst the child is still and composed. It is best, therefore, to 
perform it before auscultation and percussion, in children who are old 
enough or amiable enough to be willingly quiet, since the length of the 
examination of the thorax often wearies out their patience, and they refuse 
to submit to further inspection ; whilst, in infants and in children who ob- 
stinately resist the examination, it matters little at what particular period 
it is attempted, since it must be done at last in the midst of cries and gen- 
eral agitation. It is, at all times, a difficult and not very useful examina- 
tion, unless the patient consents to it freely and without fear. It is very 
necessary, therefore, to resort to every means to obtain this quiet consent. 
In children over a year old, this condition is to be obtained only during 
deep sleep, during the act of nursing, or, when the patient is awake, by so 
pleasing and attracting its attention by toys, by soothing voice and man- 
ners, as to cause it to forget what is passing. The reasons why the exam- 
ination is useless, unless made during a state of calm, are very obvious. 
In the first place, the contractions of the abdominal muscles give to the 
walls of the abdomen such a degree of hardness and rigidity, that it is 
impossible to learn anything in regard to the state of the parts within, 
except merely what can be learned by percussion ; and, in the second place, 
no acuteness of perception will enable us to distinguish between the cries 
of anger and fright, and those that may proceed from pain occasioned by 
pressure. 

M. Valleix recommends a plan in the case of young infants, by which 
tenderness on pressure may very generally be recognized. It is as fol- 
lows : He carries the child, carefully sustained in the arms, suddenly before 
a bright light, either that which pours in at a large window during day- 
light, or that of a bright artificial light at night. The infant, whose great- 
est pleasure consists in gazing at a bright light, almost always ceases to 
scream and becomes perfectly quiet while thus attracted. Seizing this 
opportunity, the physician should pass his hand under the clothes, and 
applying it directly over the cutaneous surface, he may first learn, by a 
rapid palpation, the general characters of the abdomen, and then ascertain 
by sudden and decided pressure whether it be abnormally sensitive. If 
the pressure gives pain, the infant will cry out at the moment, while, at 
the same time, a sudden contraction of the countenance will assist to show 
the perception of some painful sensation. Should the infant, on the con- 
trary, continue to gaze fixedly at the light, without noticing the manoeu- 
vres of the physician it is fair to conclude that there is no inflammatory 
tenderness present. 



n 



EXAMINATION OF THE MOUTH AND THROAT. 47 

Examination of the Mouth and Fauces. — In all obscure attacks 
of sickness occurring in young children, and even in those who have at- 
tained to the faculty of speech, the physician ought to be most careful to 
inspect the condition of the mouth and fauces, since not a few cases of 
fever which seem at first view inexplicable, are at once made plain by this 
simple exploration. We were once called to see a child three years of 
age, who had been sick three days with fever, thought by intelligent and 
educated parents to depend on gastric derangement. A single look into 
the throat showed it to be completely clogged up with pseudo-membranous 
exudation, whilst a slight hiss in the inspiration, and a husky voice, de- 
clared that the same fatal product was just entering the larynx. The time 
for successful action had slipped by ; the patient died two days after in the 
agonies of slow croup. On another occasion we were called to take charge 
of two children in one family who had been ailing several days with fever- 
ish symptoms, loss of appetite, languor, and some complaint of sore throat. 
In both we found the fauces covered with plastic deposit, and both died a 
few days after of membranous croup. Some yeai*s ago we attended a child 
between five and six years old, for a period of four days, with irregular 
fever, some vomiting, total anorexia, languor, indisposition to play, and 
rare complaints of pain in the chin and neck, that were not mentioned to 
us by the attendants, so that all the time we had the idea that the attack 
was one of gastric embarrassment. Greatly to our amazement and con- 
sternation, the mother informed us on the fifth day that she had seen 
something white in the throat, and upon examination we found both ton- 
sils covered with whitish exudation. Happily the exudation was still con- 
fined to these glands, and we were able by appropriate treatment to pre- 
vent its further extension. 

In croup, also, in whatever form it may make its attack, the fauces 
ought to be closely watched, in order to know by the presence or absence 
of false membrane, the probability or improbability of the case being one 
of the membranous kind. In scarlatina and measles, especially in the 
former, the throat ought to be examined each day, to ascertain its precise 
condition, and particularly to learn whether there be present any disposi- 
tion to membranous, ulcerative, or gangrenous angina. 

In young infants, also, the mouth requires a thorough examination from 
time to time in all their ailments, and especially in their digestive diseases, 
since they are liable to thrush, to aphthie, and, in chronic and debilitating 
maladies, to gangraena oris. In teething children the act of dentition re- 
quires that the mouth should be inspected occasionally in order to ascer- 
tain the state of that process, and to detect the existence of the form of 
stomatitis called ulcerative, which generally occurs between the ages of 
one and five or six years. 

The mouth can be readily examined by pressing upon the chin with 
force sufficient to cause the child to separate the jaws. In the young in- 
fant this very generally produces crying, during which the mouth is w idely 
opened, and the state of the cheeks, lips, gums, and tongue can be per* 
fectly well seen. In an older child, who refuses to open the mouth, or to 



INTRODUCTORY ESSAY. 



keep it open, the haudle of a smooth silver spoon is the best instrument 
to ein})Uiy by which to effect our purpose. 

The throat cannot be well seen at any age, except by depressing the base 
of the tongue, which is best done by means of a spoon-handle, as above 
directed. When a child refuses obstinately to open the mouth, and resists 
with violent struggles, it should be taken on the lap of a strong assistant, 
with the back of its trunk resting against the chest of the assistant, whose 
arms should restrain, by being crossed over the body and limbs of the 
child, its more vehement movements. Another assistant must hold the 
head of the child steady, whilst the physician obliges it to open the mouth, 
either by closing the nostrils with the fingers, or by slowly and gently, but 
firmly, insinuating the handle of the spoon between the teeth. After the 
spoon has once been passed over the tongue there is seldom any difficulty 
in obtaining a good view of the fauces. 

The introduction of the finger into the mouth is of some use as a diag- 
nostic means in the case of infants. It informs us of the temperature of 
that cavity, of the state of its secretions, and consequently, of its dryness 
or humidity, and of the disposition and ability of the infant to suck. 
When an infant is in goed health, it will almost always seize the finger, 
when this is placed in the mouth, and suck vigorously for some instants. 
It will do the same when it is only ailing with some slight malady, and 
in the early stage of more dangerous diseases. But, in severe and threat- 
ening illness, the infant either refuses to suck upon the finger at all, or 
does so only for an instant. When the mouth is irritated or inflamed, as 
in the various forms of stomatitis, the child will open the mouth and cry, 
and make no attempt whatever at suction. In stupor, and especially in 
coma, but little attention is paid to the finger, the infant being generally 
unconscious of its presence. 

By watching the child when put to the breast, we may acquire nearly 
the same information as that just referred to, except that the child would 
naturally make a greater eflfort to seize the nipple than the finger, and 
would therefore nurse, even though the act of so doing were painful, 
under circumstances in which it might refuse to grasp the finger at all. 
The refusal to nurse, or the nursing but little at a time, may depend on 
other causes, however, than sore mouth. It often depends on some angi- 
nose inflammation. When this is the case, it may be suspected from the 
peculiar gulping manner in which the child swallows, and from the fact 
that swallowing often causes fits of coughing. It is caused also by dysp- 
nea. An infant laboring under severe oppression from pneumonia, bron- 
chitis, or any other cause, never sucks well and steadily, but rather by 
fits and starts. The nipple is seized often with avidity, and two or three 
swallows are made in quick succession ; then follows a pause to regain 
the breath, and then again the effort of deglutition. In a few cases at- 
tended with very great dyspnoea that we have seen, the patients have 
been able to swallow only once or twice without pausing, and even then 
with very great diflficulty. 

Manner of Taking Drinks. — The remarks just made as to the in- 
ferences to be drawn from the manner in which the infant sucks, will 



VOMITING AND THE DISCHARGES BY STOOL. 49 

apply also to the mode in which both iufauts and older children drink. 
A vounjx child drinks continuously, without stopping to breathe. If, how- 
ever, it have any disorder which accelerates the respiration, it will, after 
drinking a few raouthfuls, cease, jerk its head away from the cup or 
spoon, breathe irregularly and hurriedly, and cough. These symptoms 
ought to call attention to the respiratory organs. So, if a child, whose 
breathing is not oppressed, nevertheless drinks with difficulty, slowly, 
at intervals, and apparently with pain, there is reason to suspect some 
impediment in the pharynx, and the fauces ought thereupon to be care- 
fully examined. 

We may learn also from the manner of drinking whether the child is 
thirsty or not. When it drinks often and with avidity, and yet has a dry 
mouth, it is evident that there is very great thirst. 

Vomiting and the Discharges by Stool. — The physician should 
never think his examination of a sick child concluded until he has in- 
quired as to the occurrence of vomiting, and as to the state of the dis- 
charges by stool. Not only, indeed, should he inquire as to these symp- 
toms, but he ought by all means to inspect pei*sonally the appearance of 
the matters ejected. This is especially important in regard to the dejec- 
tions, since no description of a mother or nurse, however intelligent, can 
impart to the physician the precise and accurate idea of the state of those 
discharges which even a very rapid inspection would give him. 

Vomiting is of very frequent occurrence in infancy and childhood. 
Owing to the fact that the stomach is much less curved in its shape than 
Id the adult, and that the oesophagus enters the organ close to its left ex- 
tremity, vomiting and regurgitation take place with great readiness, and 
are, therefore, very common symptoms in the diseases of early life. 

The young practitioner must beware lest he regard all kinds of vomit- 
ing in the infant as the result of disease. The nursing child is very apt 
to vomit, even when in the most perfect health, especially if it be suckled 
at an abundant breast. This kind of vomiting, however, may be readily 
distinguished from that which depends on some morbid state of the 
health, by the circumstance of the infant's ejecting nothing but the milk 
which it has swallowed, either just as it was drawn from the mother, or 
slightly curdled, and by the fact that it suffers no inconvenience what- 
ever from the act, — neither any violent effort, languor, paleness, nor faint- 
Dess. And yet we have known a young practitioner to prescribe antacids 
and absorbents to correct this kind of vomiting, which is most plainly an 
act of nature kindly intended to rid the infant of any excess of food it 
may have imbil)ed. 

In older children also, vomiting not unfrequently occurs as a conse- 
quence of overdistension of the stomach with food. When, therefore, 
after vomiting, a child seems relieved and comfortable, when any un- 
plea^'ant symptoms that may have existed prior to it moderate or disap- 
pear afterwards, it is fair to conclude that the act has been beneficial, 
and wrong to regard it as the .signal of a necessity for giving medicine, or 
for regarding the child as a patient, except insomuch as to watch lest it 

4 



50 INTRODUCTORY ESSAY. 

be sick as an after-consequence of having had the digestive power over- 
tasked. 

Frequently repeated vomiting, attended with retching and effort, and 
with paleness and exhaustion, or with fever, always indicates some con- 
siderable derangement of the health. It is impossible to ascertain the 
precise cause of such vomiting, except by a proper consideration and com- 
parison of all the symptoms the child may present. The cause may be 
in the stomach itself, consisting of an inflamed state of the organ, or it 
may be a simple indigestion without any inflammatory condition what- 
ever ; it may be that the cause lies in the intestine, being some inflam- 
mation, functional disease, or obstruction of that part; it may be pneu- 
monia or pleurisy ; it may be the approach of some of the eruptive fevers ; 
or last, and most serious of all, the cause may be some commencing lesion 
of the brain, which, though as yet determining no proper cerebral symp- 
toms, shall perhaps be destined, by its inevitable progress, to end the 
patient's life. The detection of the particular causative condition, in any 
of these forms of vomiting, can be arrived at only by a careful study of 
the whole constitution of the patient, both through the rational symptoms 
that may be present, and by a thorough inspection of the different systems 
of the body by means of the physical methods of diagnosis. 

The rule to examine with his own eyes the napkins or cloths of the child, 
ought never to be forgotten by the practitioner, when there is any reason 
to suppose that the alimentary functions are at all deranged. The number 
of the stools in the twenty-four hours ought also to be ascertained, not 
loosely and carelessly, but precisely and with certainty. Without a close 
attention to these two precautions, it is impossible for the physician to 
obtain really useful and exact notions in regard to the nature of the dis- 
order he is called upon to treat, or to judge of the degree of severity of 
the attack. 

We shall not attempt to consider in this place either the various unnat- 
ural appearances of the matters vomited, or ejected by stool, the amount 
of those substances, or the frequency with which the discharges take place, 
since these various circumstances can be treated of in the manner they 
require, only when we come to study separately the diseases of which they 
form a part. 

We shall here conclude our remarks upon the methods to be pursued in 
the clinical exploration of the diseases of children. We have only to add 
the wish that those who shall honor them with their perusal, may find them 
of some real assistance in their subsequent studies of the affections of early 
life. They are intended, of course, chiefly for the student and young prac- 
titioner ; but we cannot help hoping that they may possibly prove useful to 
some who have spent a longer time in the profession, but who have never, 
perchance, given any particular attention to the best modes of investigating 
the diseases of infants and children. 



CLASS I. 

DISEASES OF THE KESPIRATORY ORGANS. 
CHAPTER I. 

DISEASES OF THE UPPER AIR-PASSAGES. 

SECTION I. 

DISEASES OF THE NASAL PASSAGES. 

ARTICLE I. 

CORYZA. 

Defixition; Synonyms; Forms; Frequency. — Cory za is inflamma- 
tion of the mucous membrane lining the nasal passages. It is called in 
common language, cold in the head, or snuffles. 

We shall describe three forms of the disease, — the simple or mild, the 
severe, and the chronic. The severe form includes purulent and pseudo- 
membranous cor}'za. Simple coryza is very common at all ages ; it occurs 
frequently as a distinct disorder, but still more frequently in connection 
with laryngitis, bronchitis, pneumonia, measles, scarlet fever, etc. The 
seTere form of coryza is that which was called by Underwood coryza ma- 
ligna, or morbid snuffles, and which, as he stated, is very different from 
and far more serious than what is usually called snuftles. Purulent and 
pseudo-membranous cor}'za rarely occur idiopathically, but are almost 
invariably connected with angina or other disea.ses. 

The affections upon which they are most frequently dependent are diph- 
theria, measles, and scarlet fever. A full account of this complication 
will be found in the chapters devoted to these various affections. 

Chronic coryza occurs most frequently in connection with scrofula or 
hereditary syphilis. It also results from the persistence of the purulent 
form which has originated in the course of some specific fever. 

Causes. — The only clearly evident cause of simple primary coryza, iu 
most cases, is chilling of the body. Insufficient dress, — a very common 
error in this country, — too low a temperature of the nursery, and exposure 
to bad weather, may often be discovered to have been the causes of the 
attack. 



52 CORYZA. 

As already stated, acute purulent coryza usually occurs in connection 
with some general disorder, though we have occasionally met with it as an 
independent affection, for which no satisfactory cause could be assigned. 
The cases of MM. Rilliet and Barthez coincided generally with primary 
or secondary purulent or pseudo-membranous angina. From the account 
given by Underwood of coryza maligna, there can be little doubt that it 
was epidemic when observed by himself and Denman. The latter author 
states that in connection with the coryza there was a general fulness of the 
throat and neck externally ; that the tonsils were tumefied, and of a dark- 
red color, with ash-colored specks, and in some cases, with extensive ul- 
cerations ; and that some of the children swallowed with difficulty : all of 
which symptoms clearly point to severe concomitant angina. There can 
therefore be little doubt but that in reality these were cases of nasal diph- 
theria. 

Anatomical Lesions. — The Schneiderian mucous membrane is found 
reddened uniformly, or in points, rough, thickened, and sometimes softened. 
When pseudo-membrane is present, it exists either in fragments, or lines 
the whole extent of the nasal passages, and is mixed with mucus or muco- 
purulent fluid, in greater or less quantity. 

Symptoms. — The symptoms of simple coryza are sneezing, dryness of 
the nose at first, soon followed by discharge, which is very small in quan- 
tity in the beginning, and more abundant afterwards, and more or less 
disturbance of the respiration. It is only in young infants that this form 
of coryza is a disorder of any consequence in itself In older children it 
never injures the health by its own action ; it is of importance merely as 
the sign that a cold has been taken, and ought to be regarded as a hint 
given by nature of the necessity of guarding the child more carefully in 
future. But, in infants at the breast, and very young children, it assumes 
much greater importance from the very considerable obstacle it opposes to 
the act of respiration. At this early age, in fact, coryza becomes a serious 
and even dangerous disease. If primary, it causes great distress and dis- 
turbance to the child, interrupting its sleep, interfering with the act of 
nursing, and, in some instances, so impeding the function of respiration, 
as to bring on slight, and more rarely, dangerous asphyctic symptoms. 
It may, undoubtedly, occasion in weak and debilitated children, more 
or less extensive collapse of the lungs, an accident which will explain 
the imperfect performance of the hematosic function in some cases, where 
the only evident disease is this apparently insignificant one of coryza. 

Wheil simple coryza exists in connection with bronchitis and pneu- 
monia, it adds to the severity of those diseases. In children over three 
or four years old, and particularly in those who are vigorous, it seldom 
gives any serious trouble. But in young infants, and in weakly children 
of any age, its influence upon the symptoms is often very marked. The 
effort to breathe through the nasal passages, when they are partially or 
wholly occluded by the inflammatory swelling of their lining mucous 
membrane, or by abundant and viscid secretions, fatigues, and wears 
away the strength of the child, exhausts its energies, and renders it less 
able to resist the pressure of the sickness. But not only this ; — as in 



SYMPTOMS OP THE SEVERE FORM. 63 

primary coryzii, the entrance of air into the lungs is impeded, and the 
hematosic function is thereby interfered with, while at the same time, the 
existence of an obstacle to the full inspiratory movement, in addition to 
that which exists in the lungs themselves from bronchial or pneumonic 
disease, cannot but assist in the production of that collapse of the pul- 
monary tissue, which has been found of late years to coincide so often 
with the bronchitis and pneumonia of young children, and especially with 
the former. 

The reiison why coryza causes so much difficulty in young children is, 
that they persist in the eilbrt to breathe through the nose in spite of the 
obstruction of the nasal passages. They seem to do this instinctively, not, 
apparently, having the power to carry on the act of respiration through 
the mouth, or but for short periods only at a time. The constant strug- 
gle to force the air through the nose, and the necessarily smaller quantity 
that reaches the lungs, are undoubtedly the two chief causes of the symp- 
toms above described as occurring in the coryza of children. 

Severe Coryza begins with sneezing and stoppage of the nostrils, soon 
after which the discharge, which is the pathognomonic symptom of the 
disease, makes its appearance. This consists of serous or mucous fluid in 
greater or less abundance, usually of a yellowish color, and which, at first 
thin and without odor, becomes afterwards thicker and often purulent, 
with a peculiar, unpleasant, but not fetid odor. In other cases, on the 
contrary, and especially when the pseudo-membranous exudation is present, 
the discharge is thin, and often contains small granular particles, which 
seem to be the detritus of the false membrane, while at other times it is 
ichorous or even bloody. When false membrane is present, it can often 
be seen, upon examination of the nostrils in a strong light, to cover the 
mucous membrane in the form of thin adherent layers of a yellowish- 
white color. The ahe nasi, and sometimes the whole extremity of the 
nose, are red and swelled, and the skin, which is tense and shining, pre- 
sents an erysipelatous appearance. The upper lip is generally reddened, 
irritated, swelled, and sometimes excoriated, by the nasal secretion. 

The re*]nraiion i.s generally difficult, nasal, and snoring. When the 
Da.<al pas.sages are nearly or quite filled with the secretions, the child being 
no longer able to breathe through them as in health, is compelled to keep 
the mouth open. This is exceedingly inconvenient to children of all ages, 
as it causes great dryness and stifTne-ss of that cavity, and of the tongue 
and throat, and in very young infants, who instinctively respire almost ex- 
clusively through the nostrils, it is attended with such violent efforts as to 
be a chief or perhaps sole cause of the fatal termination of some ca.ses. In 
one instance that we saw, the child was seized with attacks of suffocative 
breathing, which threatene<l fatal asphyxia, whenever the passages became 
much impeded. Under these cirfurastances the cleansing of the passages 
with a brush would afford complete relief, and, for a time, the little thing 
would appear to be quite well. Finally, however, death occurred in one of 
the attacks of dyspnrea, from sudden serous effusion into the lungs. The 
difficulty of respiration is greater, as we have stated, in proportion as the 
child is younger, and depends on the physiological fact already referred 



54 CORYZA. 

to, that at a very early age, respiration is performed almost solely through 
the nostrils, and that the child seems incapable of keeping the mouth open, 
in order to compensate for their closure. We have never observed cough 
except in cases accompanied by angina. Epistaxis occurred in two cases 
of the pseudo-membranous form, in children between three and five years 
of age. The bleeding recurred on several occasions, but ceased so soon as 
the coryza was cured. Infants refuse the breast when the passages are 
much clogged, or suckle with great difficulty and at long intervals. 

The character of the general symptoms depends much more upon the 
accompanying disease, in older children, than on the coryza itself, and it is 
unnecessary therefore to dwell upon them. In the cases observed by our- 
selves, the principal symptoms have been unaccompanied by angina, rest- 
lessness, weakness, emaciation, dry, harsh, and wrinkled skin, and violent 
attacks of dyspnoea ; and in the other cases, in which angina was present, 
there were added to these, fever and somnolence. The duration, as ob- 
served by ourselves, in cases occurring in infants, has been between two 
and three weeks. In other cases, which occurred in older children, the 
duration of the attack depended on the form and degree of the attendant 
angina. In some cases it became chronic, and was accompanied by ulcera- 
tion of the nasal passages. MM. Rilliet and Barthez state that they saw a 
child two years old die in three days, and another of three years in the same 
time ; but as one of these cases was complicated with angina and croup, 
and the other with pseudo-membranous angina, it is clear that the rapid 
death depended rather on the accompanying disease, than on the coryza 
itself. 

The prognosis must depend on the age of the child, and the form of the 
attack. Simple coryza is never dangerous except in very young infants, 
and rarely in them. When, however, it occurs in a delicate infant, and is 
accompanied with either sufiicient turgescence of the nasal mucous mem- 
brane, or with enough viscid secretion, to cause a nearly complete occlu- 
sion of the nasal passages, the effort to breathe through the nose, and the 
diminished quantity of air that reaches the lungs, will sometimes give rise 
to great and dangerous exhaustion, or to partial or fatal asphyxia. In 
older children this form of the disease is never scarcely more than an 
annoyance. 

When simple coryza occurs in connection with other diseases, whether 
thoracic inflammations, angina, or measles, it always adds, and sometimes 
most seriously, to the difficulties of the patient, since the effort to breathe 
through the obstructed air-passages must assist to exhaust the life-forces, 
while at the same time a certain amount of the blood in the lungs, which 
ought to be exposed at each inhalation to the inspired air, is deprived of 
this necessary contact by the fact that less than the natural quantity of 
air is drawn through the nasal passages at each expansion of the chest. 

The purulent and pseudo-membranous forms of coryza are always dan- 
gerous, whether they occur alone or as a part of other diseases. The two 
cases of idiopathic membranous coryza in infants that came under our 
observation, both proved fatal. The four cases in older children recovered 
without any difficulty. When they occur in connection with pseudo-mem- 



SYMPTOMS OF CHRONIC FORM. 55 

branous angina, or in the course of scarlet fever, the prognosis will of 
course depend very much on that of those diseases. 

Chronic Coryza. — Under this title we shall describe as succinctly as 
possible a form of inflammation of the Schneiderian membrane, of which 
we see a good many examples. It is characterized rather by swelling and 
thickening of the mucous membrane, as far as this can be seen, and by an 
accumulation of scabs and crusts, -causing obstruction to the passage of the 
air, than by a discharge. The secretions are, in fact, not much increased 
in quantity beyond their natural amount, but they consist of very thick 
mucus, or they are purulent in character. 

This form of the disease may be met with at any age, from a few weeks 
old up to puberty. Its principal cause has always seemed to be some faulty 
state of the general health, some constitutional dyscrasia. Like the kera- 
titis and chronic otorrha?a of children, it makes its appearance without 
any evident exciting cause whatever, or it follows an acute attack of catar- 
rhal inflammation from cold, or an attack of measles, scarlatina, or epi- 
demic angina. On one.occasion, we met with it in three out of a family 
of four children. Though it is unquestionably very apt to occur in scrofu- 
lous children, its presence is not necessarily a sign that the patient is of 
scrofulous habit, since we have seen it in families in which there was no 
taint of that disease, and have known a good many of those aflfected by it 
to recover perfectly, and show no subsequent symptoms of the scrofulous 
or tuberculous cachexia. Its chief eflicient cause appears to be a low state 
of the general health, the blood being more or less markedly anemieal, 
and the nutrition of the body imperfect. In addition to the above con- 
ditions, it must also be borne in mind, as a fact of the utmost importance, 
that this form of coryza occurs frequently as a symptom of constitutional 
syphilis. 

The chief symptoms of this form of disease are of a local character. 
The breathing is at all times more or less nasal and embarrassed. Even 
in the waking state, the child will sometimes attract attention by the noisy 
and slightly oppressed character of its respiration, while when asleep the 
obstruction to the passage of air through the nasal passages will be so 
great as to give rise to symptoms which, though not alarming, are most 
annoying to those around. The obstruction to the passage of air through 
the nasal passages produces snoring or hissing sounds, which are some- 
times so noisy as seriously to disturb those sleeping in the same apartment. 
This obstruction also obliges the child to make much greater muscular 
efforts than in the healthy state, to supply the thorax fully with air, so 
that the sleep, instead of being (|uiet and easy as in health, is broken and 
disturbed by the unusual play of the muscles, and by the disordered inter- 
nal sensations caused by the reaction upon the nervous centres of a circu- 
lating fluid less thoroughly decarbonized than it should be. The child 
tosses and rolls, sighs and moans, or it cries out in its sleep, or it wakes 
suddenly and frequently. 

When the nasal passages are examined by a full light, they will be seen 
to be obstructed in two ways: by a thickened and injected state of the 
mucous membrane, and by the presence iu them of scabs, or of more or 



56 



less inspissated masses of mucus or muco-pus. The mucous membrane is 
also redder and more highly vascular than natural, and sometimes exhibits 
an appearance in some points as though excoriated or slightly eroded. 
There is seldom, indeed rarely, any considerable amount of fluid secretion, 
as in acute coryza ; the secretions are so much more viscid than usual that 
they desiccate in the passages and form scabs and crusts. Not unfrequently 
the surfaces become so irritable as to bleed very easily. The act of blow- 
ing the nose, a rude touch, or a blow, will cause a considerable discharge 
of blood, and this is often the symptom for which the practitioner is par- 
ticuhirly consulted. The voice of the child is usually characteristic : it is 
nasal ; and when the obstruction is considerable this becomes a marked 
symptom. 

The general appearance of the patient almost always shows a deterio- 
rated state of the general health ; his color is too pale ; the skin is muddy; 
the expression is languid ; the tissues are more flabby and flaccid than 
they ought to be ; and the movements are less brisk and prompt than in 
full health. Such patients wake from their sleep less refreshed than is 
natural ; their appetite is often capricious and poor; and the digestive and 
nutritive functions are impaired. The tongue is often flabby in its texture, 
pale, and more or less furred, the bowels are irregular, and the discharges 
often scanty, and of an unhealthy color and smell, or there are alternations 
of diarrhoea and constipation. 

In additioUj when the case is connected with constitutional syphilis, some 
of the other evidences of this disease may usually be detected; though we 
have, like West, met with cases where the coryza has been the only sign 
of the constitutional taint. 

The duration of this form of coryza is very indefinite. Under the most 
patient treatment, it often lasts for many months, and even when cured is 
very apt to return with or without apparent exciting causes, so that we 
have known it to last for several years. 

Treatment. — Simple coryza requires no treatment in children over two 
years of age, except attention to hygienic conditions. Young children 
may often be preserved from attacks of spasmodic laryngitis and bronch- 
itis, by calling the attention of the mother to the strong tendency which 
exists during infancy and childhood to the extension of disease, and advis- 
ing, in cases of coryza, that the child should be secluded in the house, or 
else very warmly clothed if sent out. 

In young infants, even the mildest coryza gives trouble, by obstructing 
the full freedom of the respiratory act, by interfering with the suckling, 
and by the restless and broken sleep which it induces. In such cases, all 
the treatment required is to keep the child warm, and to clear the nasal 
passages, and at the same time lubricate them by the occasional introduc- 
tion of a camel's-hair pencil, charged with glycerin or sweet oil. 

When the coryza is more severe, so as to interfere a good deal with the 
respiration, it is necessary to make use of the brush frequently, to adminis- 
ter a warm foot-bath once or twice a day, and to give a few drops of syrup 
of ipecacuanha, with sweet spirits of nitre, every two, three, or four hours. 
In such cases, the late Dr. Charles D. Meigs was in the habit, for many 



I 



TREATMENT. 57 

years past, of directing a flauuel cap to be put upou the child, and kept 
there for two or three days: — a simple, and often most effectual mode of 
treatment. The cap should be removed after two or three days, so soon as 
the coryza is relieved, as otherwise the child is apt to become so much ac- 
customed to it as! to take fresh cold when it is removed. 

In infants laboring under purulent or pseudo-membranous coryza, the 
indications of treatment are to remove the secretions as they collect, and to 
subdue the intiammation of the mucous membrane by which they are pro- 
duced. It must never be forgotten, moreover, that this form of the disease 
is very frequently dependent upon some general specific disorder, of 
which it may indeed be one of the earliest symptoms, as in diphtheria. It 
need not be said that in such cases the general treatment is of even more 
importance than the local. The fii-st indication may be fulfilled by means 
of a brush made of long camel's-hair, by throwing water or lime-water 
from a small syringe into the nasal pjissages, or, when the discharges are 
thin and tiuid, by blowing strongly into the nostrils, whilst the tongue is 
depressed by a finger introduced into the mouth, so as to allow the secre- 
tions to pass out of the posterior nares into the fauces. 

The second indication is to be fulfilled chiefly by the application of so- 
lutions of alum, nitrate of silver, sulphate of zinc or copper, and by insuffla- 
tions of difterent substances in powder. The best application is probably 
the solution of nitrate of silver, which may be made of the strength of five 
or ten grains to the ounce, or stronger, to be made use of several times a 
day, with a brush. We have also employed injections consisting of solu- 
tions of alum, of from three to six grains to the ounce. It is recommended 
by MM. Killiet and Barthez to make insufflations of powdered gum and 
alum, or of gum and calomel in equal parts, several times a day. There 
is, however, it seems to us, an objection to this method of treatment, espe- 
cially in infants, — which is, that the powders would necessarily tend to 
increase the obstruction which already exists, to breathing through the 
nose. It has been proposed also to apply a few leeches to the mastoid 
process, or over the frontal sinuses; but it seems to us that this could 
scarcely ever be advisable. 

In the form of the disease accompanied with angina, an essential part 
of the treatment must be that of the throat affection. This will be con- 
sidered in another place. 

The treatment of chronic coryza must be twofold : general and locnL 
The moet important points to be attended to in connection with the general 
treatment are the clothing, the diet, an<l the administration of tonics and 
alteratives. The clothiiifj ought to be warm during the cold seasons of the 
year. Flannel, a.s a general rule, ought to be insisted upon. The arms 
and neck must be covered, and the legs should never be exposed, after the 
very mistaken fashion amongst many persons of the present day. The 
diet ought to be strengthening and nutritious. Fresh meat"*, milk, bread, 
and good butter, and the plainer vegetables, ought to be urge<l upon the 
child. If necessary, some authority must be made use of by the parents 
to induce the patient to take a sufficient quantity of these plain, but nu- 
tritious articles of food. Pastry, cakes, candies, nuts, hot bread, sweet- 



68 CORYZA. 

meats, and all such rich, but not really substantial diet, should be forbid- 
den to as great an extent as possible. 

Of the tonics to be given, the best are the preparations of iron and cod- 
liver oil. Of the former, we prefer commonly the syrup of the iodide of 
iron, from three to five drops, at four or five years of age, three times a 
day, in half a teaspoonful or a teaspoonful of sarsaparilla syrup. Or the 
Pulv. Ferri of the Pharmacopoeia may be given, either in the form of 
powder, mixed with dry sugar, in pill, or in the shape of the chocolate 
lozenge. From half a grain to a grain, three times a day, is the proper 
dose from three or four years to six or seven. The carbonate of iron may 
be given, if it is preferred, for any cause. Either of these preparations 
of iron, or any other that may be chosen, should be combined with a grain 
of quinine, three times a day, whenever the appetite is poor, and when the 
digestive process seems to be slow and feeble. Or the child may be made 
to take half a teaspoonful of the fluid extract of cinchona, mixed with an 
equal quantity of syrup of ginger, half an hour before the meals, while 
the iron is given alone soon after the meals. When the attack is particu- 
larly obstinate, and when, also, it occurs in a subject who either inherits 
or exhibits signs of the tuberculous or scrofulous diathesis, the best remedy 
is cod-liver oil, which should be given in doses of from half a teaspoonful 
to a teaspoonful two hours after each meal. In cases of syphilitic nature, 
in addition to the above regimen and tonic remedies, we should administer 
the iodide of potassium, associated in obstinate cases with minute doses of 
bichloride of mercury. 

The local treatment must consist in the use of means intended to keep 
the passages clean and free from scabs and incrustations, and in the em- 
ployment of astringent and alterative applications. When the patient 
will submit, the nasal passages should be cleansed by means of a syringe 
once or twice a day, with tepid water, or milk and water, or with a weak 
solution of alum in water. The latter may be made in the proportion of 
from two to four grains to the ounce. If the discharges are offensive, the 
lotion used for injection should consist of the solution of chlorinated soda, 
one, two, or three drachms in two ounces of water. After the use of the 
syringe, and more or less frequently through the day, according to the 
disposition to dryness of the surfaces, these should be lubricated with some 
oleaginous application. One of the best is glycerin, or glycerin rubbed 
up with cold cream (f 5j of the former to ^j of the latter) ; or sweet oil, 
or oil of sweet almonds, may be used. These applications are best made 
by means of a carael's-hair brush. 

Amongst the astringent applications, the best are weak solutions (gr. v 
to X to water f ^j) of the nitrate of silver, which should be used only once 
a day, or solutions of the sulphate or acetate of zinc with wine of opium. 
From two to five grains of either preparation, with a drachm of wine of 
opium, to an ounce of water, make a proper application. This may be 
applied twice a day. One of the best means that we know of, however, 
after the use of the alum or soda injection through the day, is to apply the 
following ointment at night : R. Ungt. Hydrarg. Nitrat., Jss. ; Ext. Bella- 
donnie, gr. x; Axungiae, ^ss. — M. This has succeeded admirably well in 



DISEASES OF THE LARYNX. 59 

several eases in which we have used it. It should be applied, after beiug 
completely softened by a gentle heat, on a camel's-hair pencil, care being 
taken to apply it thoroughly to the surface of the mucous membrane itself, 
and not merely to the outside of the hardened scabs. 

The following case well illustrates the chronic severe form of coryza. 
It was in all probability of syphilitic nature, though circumstances ren- 
dered it impossible to determine this question. 

Case. — The subject of this case, a male, was born after an easy, natural labor, 
and appeared stronj; and well, with the exception of a little discharge of blood from 
the nose soon after birth and slight coryza, the latter of which continued until the 
child was five weeks old, when it became aggravated, and one of us was requested 
to visit the infant. It was small and puny; the skin was harsh, dry, and wrinkled, 
so that the child looked like a little old woman. It was very weak, and had con- 
stant secretions from the nostrils of thick, dark-colored pus. When the discharge 
collected in sufficient quantity to obstruct the passages, the respiration beciime ex- 
ceedingly diffiiult, as the infant seemed incapable of breathing through the mouth. 
At such moment* it seemed as though the child must die of asphyxia. If tiie nos- 
trils were cleared by any means, by syringing, by the use of a brush, or by blowing 
into them in the manner already described, the respiration would become easy and 
Dalural, until the discharge collected again, when the same scene recurred. During 
the paroxysms arising from the closure of the nasal passages, the child was entirely 
unable to take the breast, but after being relieved, had no difficulty whatever; the 
mouth was either kept shut, or if open, the tongue was observed to be pressed spas- 
modically against the roof of the mouth, so that it was impossible for more than a 
very small amount of air to pass over it; the respiration was labored, and accom- 
panied by a loud snoring or nasal sound. There was no other marked symptom, 
except a nearly constant flatulent distension of the epigastric region. On the day 
before death, the infant seemed better, appeared to have gained flesh, and looked 
more intelligent, so that the mother was gr«'atly encouraged ; but the next day it 
was seized during one of the paroxysms of sufl^acation, which did not seem to be 
worse than many preceding ones, with copious discharges of bloody and frothy 
serum from the mouth and nose, and died in about three-quarters of an hour. 

At the post-mortem examination we were not allowed to examine the nasal pas- 
sages or throat. The stomach and bowels were healthy, but much distended with 
gms. The peritoneum was healthy, but contained a considerable amount of clear 
yellowish serum. There was serous effusion in both pleural cavities, but no traces 
of inflammation. The lungs were healthy, with the exception of some ecchymosed 
points, and general infiltration with sanguineous frothy serum. The trachea and 
bronchia were natural. The h<art was lartr^r tli:in usual, but healthy in other 
respects. 



SECTION II. 

DISEASED OF THE LARYNX. 
OENKRAL REMARKS. 



There has been much confu.«?ion amongst writers on the diseases of 
children, until within a few years past, in regard to the disca.ses of the 
larjnx, each one diflTering from the other in his opinions as to the nature 



60 DISEASES OF THE LARYNX. 

of the several disorders of that organ, aud of course as to their classifica- 
tion and symptoms. From later and more rigid observation it has become 
clear, however, it appears to us, that there are but three diseases of the 
larynx which deserve to be considered as separate and distinct affections : 
these are simple erythematous or catarrhal inflammation of the larynx, 
unattended with spasm of the glottis, or, as that symptom has been em- 
phatically named, laryngismus; simple catarrhal inflammation of the 
larynx, attended with laryngismus, and called most properly spasmodic 
simple laryngitis, or more commonly simple, false, spasmodic, or catarrhal 
croup ; and lastly, pseudo-membranous inflammation of the larynx, prop- 
erly named pseudo-membranous laryngitis, and more commonly called 
true or membranous croup. There is, moreover, another disease, of which 
one of the most marked symptoms is spasm of the glottis, or laryngismus, 
attended w^ith a hoop or stridor, which is now known by the name of laryn- 
gismus stridulus, but which is called also Kopp's or thymic asthma, spasm 
of the glottis, and croup-like convulsion. This disease has often been con- 
founded with the above-named affections of the larynx under the common 
title of croup, or has been supposed to constitute a distinct disease of the 
larynx ; whereas now it is well known that the laryngismus whence its 
name was taken, is but one of many symptoms that mark the dependence 
of the disease upon disordered action of the reflex portion of the general 
nervous system. 

We are well aware, also, that some most competent observers describe a 
purely spasmodic affection of the larynx, under the title of spasmodic 
croup, which they believe to be entirely independent of laryngeal inflam- 
mation, and to consist in a mere momentary contraction of the sphincter 
muscle of the larynx, produced by the sympathies which that part holds 
with other parts of the body, and especially with the digestive apparatus. 
As we have never, however, in what has now become a very considerable 
experience in the diseases of children, met with a case of spasmodic croup 
unconnected with more or less evident catarrhal inflammation of the 
larynx, we are not disposed to risk increasing the confusion already at- 
tending this subject, by making additional and more minute varieties of 
these affections than those above named. We are quite willing to ac- 
knowledge that, in some cases of simple spasmodic croup, the amount of 
catarrhal inflammation of the larynx is slight, and that the symptoms of 
digestive disorder are very strongly marked, but in not a single instance 
of croup that has come under our notice, have we ever had reason to sup- 
pose that the croupal symptoms were dependent solely on simple spasm of 
the glottis (caused by some distant irritation), unattended with inflamma- 
tion of the laryngeal mucous membrane. In all such cases that we have 
met with, it has seemed to us that the condition of gastric, intestinal, or 
bilious disorders, might be explained in one of two ways. Either the 
disorder of the digestive function has rendered the child unusually sus- 
ceptible to cold, by having diminished its power of resistance to the 
weather ; or, the derangement of the bodily functions caused by the cold 
has weakened, amongst others, the digestive system, and thus brought about 



SIMPLE LARYNGITIS WITHOUT SPASM. 61 

various symptoms of gastric or iutestiual disturbauce, or more cominouly 
of iiuliiiestioii. 



ARTICLE I. 

SIMPLE LARYNGITIS WITHOUT SPASM. 

Definition ; Frequency. — This disease consists of simple erythema- 
tous or catarrhal iuflammation of the mucous membrane of the larynx, 
unattended with spasmodic closure of the organ. It is sometimes attended 
with ulceration, but is unaccompanied by exudation of false membrane. 
The frequency of the disease, during infancy and childhood, is very con- 
siderable ; so much so, that not a winter passes without our meeting with 
a good many well-marked cases. 

Predisposing Causes. — The disease occurs at all periods of childhood, 
but seems to be more frequent under than over five years of age. Of 
sixty-two well-marked primary cases that we have met with in which the 
age was noted, fifty occurred in children under, and only twelve in those 
over that age. Of the former class, twelve were under one year, seven- 
teen between one and two, nine between two and three, five between three 
and four, and five between four and five. Of sixty-four cases in which 
the sex was noted, thirty-six occurred in boys, and twenty-eight in girls. 
As to the influence of the seasons, it may be stated that it is by far the 
most common in the fall, winter, and spring months. 

The only exciting causes of the disease which appear to have been ascer- 
tained with any certainty, are the action of cold, the positive influence of 
which cannot be questioned ; the itispiration of irritating substances, such 
as gases, smoke, powders floating in the air, etc. ; and violent efforts of 
cn'ing. MM. Rilliet and Barthez state that they have twice known 
erythematous and ulcerative laryngitis to follow long-continued and vio- 
lent crj'ing; and M. Billard also cites this as a cause. We are acquainted 
with one case in v.hich a slight attack of the disease appeared to have 
been brought on solely by loud and obstinate screaming. 

The di.scase is very apt to occur in the course of other maladies, and 
particularly of measles, small-pox, scarlet fever, bronchitis, and pneumonia. 

Anatomical Lesions. — The anatomical alterations may consist of 
simple iuflammation of the mucous membrane, with its various effects, 
or of the same changes in connection with ulceration. The latter class 
of lesions is almost always confined to secondary cases. In the former 
class, the mucous membrane varies in color between a deep rose and 
violet red, which may be either uniform or only in patches. In severer 
cases, the tissue is at the same time softened or roughened, and sometimes 
thickened. When redness, softening, and thickening are present, the dis- 
ease is generally confined to certain parts, and commonly to the epiglottis, 
and internal portions of the vocal cords; but when redness alone exists, 
it usually affects the whole of the larynx, and sometimes extends to the 



62 SIMPLE LARYNGITIS WITHOUT SPASM. 

trachea. In cases attended with ulcerations, these alterations exist in 
connection with those already described. The ulcerations are generally 
small, few in number, very superficial, linear in shape, and are almost 
always found upon the vocal cords. They are so slight often as to escape 
observation, unless a very careful examination be made ; and this, per- 
haps, explains the circumstance of so few persons having met with them 
in the simple acute disease. 

Symptoms; Course; Duration. — The attack generally begins with 
an alteration of the voice or cry. In infants the change in the cry alone 
exists, so that to detect the disease, it is necessary to hear the child cry. 
In older children the same alteration of the cry is present, but there is in 
addition a change of the voice, consisting of various degrees of hoarse- 
ness. These symptoms may be so slight as to be observed in the cry only 
when it is strong and forcible, and in the voice so as to strike only the 
ear of one accustomed to be with the child ; or they may be so marked as 
to be heard in the faintest cry that is uttered, and to be evident in the 
voice in a moment to the most careless observer ; or there may be com- 
plete aphonia. They are often intermittent in this form, and are gener- 
ally most marked in the after part of the day and during the night. 
Simultaneously with this symptom, or very soon after, cough occurs. 
This is generally hoarse and rough, and early in the attack, dry ; at a 
later period it usually becomes loose, and as this change occurs loses its 
character of hoarseness. The frequency of the cough is variable, but 
usually moderate ; as a general rule it is most frequent in the evening, 
and early in the morning, particularly in infants and young children. 
The disease is almost always preceded and attended with some coryza, 
which, in the early stage, is marked by sneezing and slight incrustations 
about the nostrils, and at a later period, by mucous and sero-mucous dis- 
charges. The respiration remains natural, except that it is sometimes 
nasal, and sometimes a little accelerated. There is rarely any fever, or it 
is slight, and occurs only at night. There is no pain in the larynx. In 
some cases, the hoarseness of the cry, voice, or cough scarcely exists, or is 
but slightly marked, and the only symptom is a dry, hard, teasing, and 
paroxysmal cough, which, from its sound, evidently proceeds from the 
larynx, and resembles very much that produced by the tickling of a for- 
eign body in the throat. 

The symptoms of this disease, instead of being of the mild character 
just described, may be much more severe. The cough is more frequent, 
hoarse, troublesome, and painful, from the scraping and tearing sensations 
it occasions in the larynx. The voice is more affected, becoming from 
husky more and more hoarse, though it is very unusual for it to become 
weak and whispering, as in membranous and severe spasmodic croup. 
The respiration is decidedly accelerated, giving rise to slight dyspnoea, 
and there is more or less fever, which is most marked usually in the after 
part of the day and in the night. The pulse is more frequent than in 
health, rising to 120 or 130 in the minute ; the skin is hot and dry ; the 
child is thirsty, restless, and uncomfortable. After a few days usually, 
the cough becomes loose and easy, and ceases to be painful ; the voice 



SIMPLE LARYNGITIS WITHOUT SPASM. 63 

loses its hoarse tone gradually, the fever disappears, the appetite and 
gavety return, and the child regains its usual health. 

When the laryngeal inflammation becomes violent in this disorder so 
as to be attended with considerable swelling of the mucous membrane, the 
case always, according to our experience, assumes the shape of grave spas- 
modic laryngitis. To our article upon this latter affection, spasmodic 
croup, we must refer the reader for further information on this point. 

In nearly all the cases of this form of laryngitis that have come under 
our observation, we have found, upon examining the fauces, more or less 
decided intiammation of the tonsils, soft palate, and pharynx. In cases 
following a rather chronic course, from two to four or six weeks, which are 
rarely accompanied by fever or hoarseness, except at the invasion, and 
sometimes in the evening, the pharyngeal mucous membrane presented a 
roughened, thickened appearance, and the tonsils and uvula were more or 
less enlarged and tumefied. 

There is a form of obstinate, troublesome cough, to which children are 
subject, and of which we have met with a good many examples, that must 
be noticed here. It depends evidently upon chronic inflammation, with 
thickening of the mucous membrane lining the upper portion of the larynx. 
Of this we teel assured, not from any post-mortem examination, since we 
have never known a child to die of, or while laboring under the affection, 
but from the tone and character of the cough, from its occasional associa- 
tion with hoarseness of the voice, from its being almost invariably coinci- 
dent with thickening and granulation of the pharyngeal mucous membrane, 
and from the fact that the most careful physical examination of the chest 
fails to reveal any disease whatever of the lungs. The cough is harsh, 
rough, and, so to speak, tearing in its character. It often sounds, especi- 
ally towards evening and in the early part of the night, croupal in its tone. 
It is usually very frequent, not so much, however, during the day, as in 
the evening and night. It is very generally increased by the horizontal 
position, so that when the child is put to bed, he will begin to cough vio- 
lently and almost incessantly, and will continue to do so for one, two, and 
even three or four hours. The cough is so constant and so severe as to 
cause the greatest disturbance not only to the patient, who will toss and 
turn in bed in the most restless manner, but to the mother or attendants, 
who are excessively annoyed, and sometimes alarmed, by its constancy 
and obstinacy. Children who become subject to this species of cough, 
often have repeated attacks during the cold seasons of the year, the slight- 
est exposure sometimes bringing them on. Each attack may last from a 
few days to several weeks. In one case we knew it to last, without once 
entirely ceasing, three months, and in another it lasted, with imi>erfect 
suspensions of a few days, during the same length of time. Both these 
cases occurred in hearty boys, one in the second, and the other in the third 
year of life, and yet both were vigorous and healthy children, as time has 
shown. In many other instances, we have known it last two, three, and 
four weeks, proving all that time most troublesome and rebellious to treat- 
ment. During the day, the child generally seems perfectly well, or at 
most merely a little pale and languid, and be coughs but moderately, but 



64 SIMPLE LARYNGITIS WITHOUT SPASM. 

as soon as night comes on and especially when he is put to bed, the cough 
begins and goes on for hours, as stated above, unless some remedy, and 
particularly some opiate, be given to check it. It is most annoying to the 
practitioner, for he finds that his usual remedies act merely as palliatives. 
They check and modify, perhaps overcome it for a time, but the next 
change in the weather, and especially the least exposure to cold and damp, 
start it afresh, and he has to resort again to the same round of treatment 
to subdue it. To the members of the family also it gives great anxiety. 
At first, they fear it must run into croup, which, however, it very seldom 
does, and then, finding how difficult it is of cure, and how often it recurs, 
they can scarcely be persuaded that it does not depend on some serious 
disease of the lungs. 

The principal cause of this form of chronic laryngeal irritation is, so far 
as we have been able to ascertain, an unusual susceptibility of the laryn- 
geal mucous membrane, sometimes the result of a congenital idiosyncrasy, 
and at other times the result of influences coming into action after birth, 
and especially of improper dress. We have generally met with it in chil- 
dren dressed upon the hardening system so much in vogue with many of 
our most highly educated citizens. The low frock, leaving the neck and 
upper half of the chest exposed to the air, the bare arms and bare legs, 
persevered in through our cold autumns, winters, and springs, have 
certainly, in most cases, been the cause of this troublesome and chronic 
cough. ' 

Our experience since the publication of the last edition fully confirms 
the truth of these remarks upon the style of clothing just referred to. We 
certainly do not see so many cases of obstinate laryngeal cough as we for- 
merly did, for the simple reason that but few of the families we take care of, 
adhere to the old-fashioned system of leaving their children half naked. 

The duration of the disease varies according to its form and the circum- 
stances under which it occurs. When primary, it lasts usually from a few 
days to one or two weeks, but when it becomes chronic, as we have known 
to happen in a good many instances, it has lasted from two to four or six 
weeks, and even two or three months. The duration of secondary cases 
depends, of course, upon that of the disease during which they occur. 

Diagnosis. — The diagnosis of simple laryngitis is very easy. The 
hoarseness of the cry, voice, and cough, the redness of the mucous mem- 
brane of the pharynx, and the absence of general symptoms, will distin- 
guish it from any other affection. In somewhat severer cases of this form, 
in which the cough is more frequent and harassing, the general symptoms 
more strongly marked, and the respiration somewhat hurried and op- 
pressed, the attack may at first view present the appearances of bronchitis 
or pneumonia. The absence of the physical signs of these affections will 
show at once, by negative evidence, the true nature of the case. 

In some cases in which there is little or no hoarseness of the voice or 
cough, the symptoms strongly resemble the early stage of hooping-cough. 
We have met with five instances in which it was difficult not to believe, 
for two and three weeks, that the attack was really one of that disease. 
In one of these the resemblance was so close, that for several days there 



TREATMENT. 65 

was a distinct hoop during the fit of coughing, with vomiting at the close 
of the paroxysm. The grounds for deciding that the case alhided to was 
not one of pertussis, were, that the attacks came on like laryngitis, after 
measles, and that the paroxysms occurred only at night. In the other 
cases a correct diagnosis was arrived at only by attention to the state of 
the fauces, which are almost always more or less inflamed and thickened 
in laryngitis, whilst they are not so in pertussis, and by watching the prog- 
ress of the sickness. 

Prognosis. — The prognosis is always favorable in the mild form of the 
disease. We have never met with a fatal case. 

Treatment. — The treatment of the milder cases of this form of laryn- 
gitis ought to he very simple. Children under four or five years old ought 
to be confined for the first few days to the house, unless the weather be dry 
and not intensely cold. In mild weather they may be sent out for a short 
time in the middle of the day. When the patient is five or over, he may 
continue to go out through the day, unless the weather be very bad. Much 
must depend upon the peculiarities of the child's own constitution. These 
can only be learned by observation on the part of the mother. Some 
children bear going out with such attacks perfectly well ; others, if sent 
out with this simple laryngitis, are almost certain to have spasmodic croup 
or bronchitis more or less severely. When there is any febrile movement 
in the case, no matter how slight, the child ought to be kept quiet, and 
confined to the house. Attention to this point, therefore, careful manage- 
ment of the clothing, slight reduction of the diet if there be any fever, a 
warm foot-bath at night of simple water, or of water containing a little 
mustard, the application of some slightly stimulating liniment to the front 
of the neck and throat twice a day, and the occasional internal adminis- 
tration of some gentle expectorant and anodyne dose, constitute all that is 
necessary in the great majority of cases of this kind. The best internal 
remedies are a few drops of syrup of ipecacuanha, with paregoric, lauda- 
num, or solution of morphia given every evening as the child is put to bed, 
or occasionally through the day also, if the cough is troublesome. A com- 
bination of syrup of seneka with that of ipecacuanha, will often be found 
ver>' serviceable. 

The treatment of the chronic laryngeal cough, unattended by fever or 
any severe constitutional symptoms, described above, requires some special 
remarks. In the first place, we have to state we have seldom succeeded 
in curing it until we had obtained from the parents their consent (often 
obtained with great difficulty) to a proper dress for the child. Expector- 
ants, nauseants, opiates, antispasmodics, counter-irritants, and local aj)pli- 
cations, have nearly always failed to procure more than temporary alhvia- 
tion, until the child has been dressed warmly. We have cured, on several 
occasions, this kind of cough, after many ineffectual trials with the above 
remedies, only by insisting upon a mode of dress which covers the neck, 
arms, and lower extremities. A merino or soft flannel shirt, with long 
sleeves and high neck, long merino stockings, and thick muslin or canton- 
flannel drawers, have done more in such cases to eflTect a cure than all 
other means. This style of dress has removed the cause, the constant 

6 



66 



SIMPLE LARYNGITIS WITHOUT SPASM. 



chilling of the body, and then the usual therapeutic measures will, no 
doubt, assist in overcoming the local changes which constitute the disease. 
The best therapeutic measures to be adopted in such cases are the appli- 
cation, once a day, of a solution of nitrate of silver, of from five to twenty 
grains to the ounce, low down into the pharynx and chink of the glottis, 
by means of a small sponge-mop on a bent whalebone. After several ap- 
plications have been made daily, they should be made only once in two or 
three days. The strength of the solution is to be determined by the con- 
dition of the pharyngeal mucous membrane, as we may assume this to 
mark, in seme measure, the state of the contiguous tissue of the glottis. 
When the mucous membrane of the fauces is covered with large, pro- 
tuberant follicles, when the tissue between the follicles is thickened, re- 
laxed, spongy-looking, and when the color of the membrane is dark- red, 
the stronger solutions are the best ; when, on the contrary, the mucous 
membrane is not roughened or thickened materially, when the follicles are 
small, when the color of the tissues is bright-red, it is best to use only the 
five-grain, or even a weaker solution. The most useful internal treatment 
in our hands has been the exhibition, three times a day, of one of the fol- 
lowing mixtures, preferring that with antimony for a vigorous child, and 
that without antimony for one less robust. 



R. — Potass. Carbonat., 


• . . • BJ. 


Vin. Antiipon., . 


. f^^ss. vel j. 


Tinct. Opii, 


. gtt. xxiv, vel xlviij 


Syrup. Simp., . 


. . . . fSh 


Aq. Cinnamom., 


. . . f^ij— M. 


Ft. Mistura. 




R. — Potass. Carbonat., 


. • . BJ. 


Tinct. Opii, 


. gtt. xxiv, vel xlviij 


Syrup. Senegffi, . 


• . . f^ij- 


Syrup. Tolutani, 


• . . f^vj. 


Aq. Fluvial, 


. . . f^ij— M. 


Ft. Mistura. 






One of the most troublesome cases of cough we ever met with, occurred 
a few years since in a fine, intelligent, but not robust boy, four years old. 
He was seized with a hard, obstinate cough, which, in a few days, became 
really terrible from its almost incessant repetition for many hours at a time. 
The cough was dry, tickling, choking, repeated with nearly every breath, 
and so incessant as to drive the parents — and we may add the doctor — 
almost frantic. The little fellow at last found out, instinctively, that, by 
placing himself on the front of the body on two pillows, with the chin 
hanging over the edge of the upper one, he coughed less frequently, and 
with less violence, than in any other position. Discovering that the uvula 
was very much lengthened from relaxation and elongation of its mucous 
membrane, we touched the lower, sharp extremity with the lunar caustic 
stick twice a day. At the same time the following mixture, which we had 
often used to control general nervous irritability in children, was pre- 



SPASMODIC SIMPLE LARYNGITIS. 67 

scribed ; and this, with the lunar caustic application, finally controlled the 
cough. It was as follows: 

R.— Vin. Antimonii, gtt. xlviij. 

Ext. Valeriana? FL, 

Tr. Opii Camph., aa, f^ij. 

Syrup Simp.. ^,^=^^- 

Aqua? f5J— ^'^• 

S. A teaspoonful every hour or two when the fits of coughing set in. 

After a few days, when the irritability of the fauces was somewhat 
subdued, the elongated portion of the mucous membrane of the uvula 
was cut off close to the muscle, and there was no renewal of the cough 
afterwards. 

When the cough is very harassing at night, from two to four drops of 
laudanum, with from ten to twenty drops of syrup of ipecacuanha, or two 
grains of Dover's powder, given once or twice in the evening, have answered 
better than any other means. When the patient presents an anemical ap- 
pearance, or other symptoms marking a general deterioration of the health, 
iron, and especially the syrup of the iodide of iron, given three times a day, 
has assisted in removing the cough, and especially in lessening the extreme 
susceptibility of the system to changes of the weather. The diet ought to 
be light, but strengthening. Good fresh meat, with simple nutritious vege- 
tables for dinner, and bread and milk morning and evening, constitute the 
most proper diet. In bad weather, during the cold seasons of the year, the 
child should be confined to the house. 



ARTICLE II. 

SPASMODIC SIMPLE LARYNGITIS, OR SPASMODIC OR FALSE CROUP. 

Defixitiox ; Synonyms ; Frequency ; Forms. — Spasmodic laryngitis 
is a disease of the larynx almost peculiar to children, consisting of simple 
catarrhal inflammation, without pseudo-membranous exudation, of the 
mucous membrane of that organ, attended with sj)a.^modic contraction of 
the glottis, or laryngismus, occasioning violent attacks of threatened suffo- 
cation. 

It is the disease commonly called in this country croup, or, by those who 
make the distinction between it and pseudo-membranous laryngitis or true 
croup, spasmodic croup. It is known also by the names of false or pseudo- 
croup. We prefer the term spasmodic laryngitis, because it is expressive of 
the essential characters of the disea.*e. It is the .stridulous laryngitis of 
MM. Guersent and Valleix ; the stridulous angina of M. Bretonneau ; the 
acute a.'^thma of infancy of Millar ; and the spasmodic croup of Wichmann, 
Michaelis, and Double. It is not the lar}'ngismus stridulus described by 



68 SPASMODIC SIMPLE LARYNGITIS. 

the English authors, Kerr, Ley, and Marsh, which is the same as the 
thymic or Kopp's asthma of the Germans, and spasm of the glottis of the 
French. It is called by Dr. Wood, in his work on the practice of medi- 
cine, catarrhal croup. 

Spasmodic laryngitis is one of the most frequent of the diseases which 
occur during childhood in this country. It is so common in this city, that 
almost all mothers who have had any experience in sickness, keep some 
remedy for it in their houses, which they are in the habit of resorting to 
upon their own judgment. 

During the last 20 years we have had under our charge 109 cases of the 
disease, of which we have kept an accurate record, and at least 100 other 
cases, of which we have no written account. Of the 109 cases, 86 were of 
the mild, and 23 of the severe form. 

We shall describe two forms or degrees of this disease, the mild and the 
severe. Without this distinction it would be impossible to give an accurate 
account of the disorder, since the two forms differ so much in aspect as to 
render them almost as much unlike as though they were two distinct af- 
fections. Moreover, the mild form differs so widely from membranous or 
true croup in its course and symptomatology, that the distinction between 
the two is readily made out, whilst the severe form, on the contrary, resem- 
bles true croup so much as to demand often very nice powers of observation 
to distinguish them, and yet the distinction is one of vast consequence to 
the patient, since the prognosis and treatment are widely different in the 
two diseases. 

Predisposing Causes. — The disease is much more common at some 
ages than others. It occurs most frequently during the period of the first 
dentition, being more common in the second year of life, which is the 
time of greatest activity of the first dentition, than at any other age, 
though it is often met with also in the third and fourth years. In the 
fifth year it still occurs occasionally, in the sixth and seventh it becomes 
rare, and after the seventh we have seen it but a few times. Of 106 
cases of the disease that we have attended, in which the age was noted, 
8 occurred in the first year of life, 33 in the second, 22 in the third, 26 
in the fourth, 12 in the fifth, 2 in the sixth, 2 in the seventh, and 1 in the 
eighth. 

It is said to be more frequent in boys than girls, and this seems borne 
out by our own experience, since of 106 cases, 62 occurred in boys, and 
44 in girls. 

Spasmodic croup occurs usually as a sporadic disease, but is said by some 
authors to prevail at times as an epidemic. We have never had any reason 
to suppose that it was strictly an epidemic like membranous croup, which 
appears to a considerable extent in some years, and in others is scarcely 
seen. We believe rather that the unusual prevalence of spasmodic laryn- 
gitis at certain periods, in comparison with others, depends on the fact that 
certain states of the weather or season predispose or excite to it in a greater 
degree than usual, and thus occasion a large number of children to be 
attacked with it. 

It is generally believed to be hereditary in certain families, and of this 



ANATOMICAL LESIONS. 69 

we ourselves have uo doubt. We are acquainted with one family in this 
city, in which the children for three generations were extremely liable to 
it; with another, in which the grandmother and grandchildren were fre- 
quently attacked ; and with a third, in which the father and children 
showed the same predisposition in the most marked manner. The idea is, 
moreover, entertained by many people in this community. 

The natural constitution of the child does not seem to have much influ- 
ence upon the liability to the disease; it occurs indiflerently in the weak 
and strong. We have no doubt, however, that there are certain transient 
conditions of the health which do aff*ect the liability to it, since it has long 
been remarked that disturbances of the digestive functions frequently invite 
it, and since we have often ourselves found it most apt to attack those who 
are liable to it, when they happen to be laboring under bilious disorders or 
indigestions. It is most common during cold weather. 

Exciting Causes; Cold. — By far the most frequent exciting cause is 
the action of cold ; either the passage from a warm into a cold atmosphere, 
or prolonged exposure to cold and damp. It has been known on several 
occasions to follow long-continued crying, doubtless from inflammatory 
action set up in the larynx, as a consequence of the excessive determina- 
tion of blood to that part during the act of crying. We were assured, 
some time since, by a very intelligent woman, that her little daughter 
had, at the age of two years, a well-marked attack of croup, after a severe 
and long-continued fit of crying from some contrariety. 

Anatomical Lesions. — Mild cases of spasmodic laryngitis are so 
rarely fatal, as to leave us in some doubt as to the character of the ana- 
tomical lesions, or whether there are indeed any perceptible alterations of 
the tissues. We have never ourselves met with a fatal case of tliis form, 
and are therefore unable to give any personal account of the condition of 
the lani'nx, though we have never doubted, from the nature of the symp- 
toms, the hoarseness, the dry cough, which afterwards becomes loose, and 
the whole aspect of the disease, that the anatomical condition of the af- 
fected organ must be one of slight inflammatory hyper?emia. In some 
cases, however, that have been examined, a little mucus in the larynx, and 
slight redness have been found, while in others no change has been detected. 
Dr. Wood (Trent, on the Prac. of Med., vol. i, p. 779) accounts for this 
absence of morbid appearances in the following plausible manner: "In 
some rare instances, no signs of disease are discovered in the mucous mem- 
brane, and the patient has probably died of spasm, consequent upon high 
vascular irritation or congestion, the marks of which disappear with life." 

Cases of severe spasmodic croup have not unfrequently proved fatal, and 
the anatomical alterations of this form of the disea.sc have therefore been 
well ascertainerl. These alterations consist of either simple ratarrlial 
inflammation of the laryngeal murous membrane, or of inflammation 
attended with ulceration. When the inflammation is simple, the mem- 
brane is changed in color, either uniformly or in spots, to a deep rose or 
dark-refl tint. This may be the only alteration, or the tissues may be 
found also softene^l, or roughened and thickened. When the redness, (liirk- 
ening, and softening, are all present, these appearances are usually confined 



70 SPASMODIC SIMPLE LARYNGITIS. 

to certain parts, and particularly to the epiglottis and vocal cords, but 
when redness alone is present, it generally affects the whole of the larynx, 
and may extend to the trachea. To the alterations just described are 
sometimes added, as was stated above, ulcerations. These are commonly 
small, few in number, of a linear shape, and are usually seated upon the 
vocal cords. They are so slight as to escape observation, unless carefully 
looked for. 

Symptoms; Duration. — The invasion of the mild foiTu of spasmodic 
croup is generally very sudden, for though it is often, probably in a large 
majority of cases, preceded for a few hours or a day or two by slight coryza, 
hoarseness, and cough, these symptoms are seldom noticed at the time, and 
the child is not supposed to be sick until seized with the paroxysm of suffo- 
cation, which is pathognomonic of the disease. This occurs in much the 
larger number of cases during the night, and very generally wakes the 
child from sleep. Of sixty-four cases observed by ourselves, in which the 
time of the attack was noted, it occurred in the night in sixty-two, whilst 
in two it came on in the afternooon. The period of the night at which it 
takes place is very irregular, but it is much more apt to be before than after 
midnight, as is shown by the fact that of forty-two cases in which this cir- 
cumstance was. ascertained, the attack was before midnight in thirty, and 
after in twelve. This agrees very closely with the statement of MM. 
Killiet and Barthez, that it has been observed most frequently at eleven 
in the 'evening. The duration of the paroxysms varies considerably, and 
depends a good deal upon the treatment employed. They may last from 
a few minutes to several hours, but are seldom shorter than from half an 
hour to an hour. The number of the attacks also varies. In some cases 
there is but one, though very generally there are several; When the attack 
occurs early in the night, it is very apt to recur again towards morning, 
and, unless means of prevention are used, on the following night also, and 
even, though this happens much more rarely, on the third night. As a 
general rule, the first attack is the most severe. 

When the paroxysm comes on, the child is wakened from sleep by the 
sudden occurrence of symptoms apparently of the most alarming and 
dangerous character. These consist of loud, sonorous, and barking cough ; 
of prolonged and labored inspiration, accompanied by a shrill and piercing 
sound, to which the term stridulous is applied ; of rapid and irregular 
respiration, amounting often to violent dyspnoea, or seemingly impending 
suffocation ; the child, alarmed and terrified at its condition, and at the 
fright of those around, its countenance expressive of the utmost anxiety, 
cries violently between the attacks of coughing, and begs to be taken on 
the lap, or sits up or tosses itself upon the bed, struggling apparently with 
the disease, which seems for the moment to threaten its very existence. 
The voice and cry are hoarse, and sometimes almost extinguished during 
the height of the paroxysms, but become distinctly audible, and often nearly 
natural, in the intervals between them ; differing in this respect from pseudo- 
membranous croup, in which they remain permanently hoarse or whisper- 
ing. We have never heard, in this disease, the whispering voice and the 
short smothered cough of true croup. The face, head, and neck, are at 



1 



SYMPTOMS. 71 

first deeply flushed, aud as the paroxysm becomes more violent, assume a 
dark livid tint, which atterwanls passes into a deadly paleness, if the attack 
be long continued. These changes in the coloration depend upon the arrest 
of the respiratory function and a consequent partial asphyxia. The pulse 
is frequent during the paroxysm, and the skin sometimes heated. After a 
longer or shorter period, generally from half an hour to an hour, the res- 
piration becomes more tranquil ; the stridulous sound disappears entirely, 
unless the child be disturbed and made to cry, when it again becomes dis- 
tinct ; the cough is less frequent and less boisterous, and the child generally 
falls asleep. The attack is very apt to recur towards morning, as has been 
stated, and if not then, the following night. The patient often seems per- 
fectly well the day after the first paroxysm, with the exception, perhaps, 
of slight cough. This is no reason, however, for supposing that the dis- 
ease will not return in the course of the second night, which is almost sure 
to hapi^en, unless measures be taken to prevent it. The cough generally 
continues for a day or two, but soon loses the peculiar character expressed 
by the term croupal ; it becomes less frequent and more loose, and the child 
is commonly well again in two or three days. Sometimes, however, the 
cough lasts for several days, becoming gradually less frequent, until at last 
it ceases entirely. 

There is very little fever in mild cases, for though the pulse is accele- 
rated and the skin warm during the paroxysm, these symptoms disappear 
very soon after that is over. In more severe cases, on the contrary, there 
may be considerable fever, the pulse becoming frequent aud full, and the 
skin hot. The febrile movement is most apt to occur after the first parox- 
ysm, as a consequence, apparently, of the slight catarrh which remains 
after the attack. 

In the few fatal cases on record, the paroxysms have generally become 
more frequent and more violent by degrees, and death has occurred from 
suffoc-ation. In other instances, death has been the result of prostration, 
which itself ha.s probably depended on imperfect hematosis. 

Recurrences of the disease are very common, children sometimes having 
several attacks in a single winter. This is not the case in true croup. We 
have known but two children to have a second attack of that disease. 

The $evereform of spasmodic laryngitis may begin as such or result from 
an aggravation of the mild form ; or the case may commence as one of 
simple laryngitis without spasm of the glottis, and as the intensity and 
extent of the laryngeal inflammation increase, it may assume all the fea- 
tures of the form under consideration. Whatever be the mode of onset 
of the case, this form of the disease sets in with hoarse, frecjuent cough, 
difficult respiration, restlessness, and more or less violent fever, symptoms 
which almost always become severe for the first time at night, and usually 
between early evening and midnight; though, in some few cases, they 
make their first appearance during daylight, and this is very much more 
apt to happen in this than in the mild form of spasmodic croup. During 
the night the symptoms increase in severity ; the respiration is frequent 
and difficult, and, after a time, attended with the stridulous sound in in- 
spiration aud expiration caused by narrowing of the glottis ; the cough is 



72 SPASMODIC SIMPLE LARYNGITIS. 

hoarse, dry, and croupal, and unattended with expectoration ; the voice 
becomes hoarse, and fever sets in, the pulse becoming full and frequent, 
the skin hot and dry, and the face flushed. These symptoms persist, with 
greater or less severity, throughout the night, while from time to time, 
they increase to such an extent as to seem to threaten suffocation, resem- 
bling then exactly the paroxysms described as occurring in the mild form 
of the disease. They usually subside, however, very decidedly towards 
morning, the breathing becoming easier, the stridulous sound less loud, or 
ceasing altogether, the fever diminishing, and the patient becoming in all 
respects much more comfortable. This amelioration of the child's con- 
dition often continues until the after-part of the day or till evening, when 
the same train of symptoms reappears. In other cases the disease scarcely 
subsides at all for two, three, or four days, but continues throughout the 
day and night to exhibit the same symptoms as have been described 
above. In cases of this kind, which are not rare, the disease assumes 
many of the alarming and dangerous characters of pseudo-membranous 
laryngitis or true croup, and it becomes very difficult often to distinguish 
between the two. If no favorable change take place, the dyspnoea be- 
comes so violent as to threaten suffocation ; the cough is rare and short ; 
the voice is reduced to a mere whisper ; the pulse becomes small, extremely 
rapid and thready ; the countenance, at first livid and congested, assumes 
a pale, cadaveric appearance ; the features are contracted ; the child be- 
comes comatose or delirious, and death occurs from slow asphyxia, or 
sometimes in an attack of general convulsions. 

In favorable cases, on the contrary, the dyspnoea, and especially the 
stridulous sound, diminish ; the cough becomes loose, less hoarse, and loses 
its croupal character ; expectoration of mucous sputa takes place in older 
children, whilst in younger, the loose gurgling sound produced by the dis- 
charge of the sputa into the fauces, is heard at the termination of each 
cough; the voice becomes clearer and stronger; the fever diminishes; the 
child regains its spirits and disposition to be amused ; and soon all dan- 
gerous symptoms have disappeared, and the recovery is established. 

In nearly all the cases that have come under our observation, we have 
found, upon examining the fauces, more or less decided inflammation of 
the tonsils, soft palate, and pharynx. 

The duration of the severe form of spasmodic croup depends on the vio- 
lence of the attack, and on the mode of treatment. When the treatment 
is begun with from an early period, the disease is much sooner overcome 
than when allowed to run on for some time without remedies. In cases of 
moderate severity, the violence of the symptoms usually subsides after 
thirty-six or forty-eight hours. In more violent cases, on the contrary, 
the symptoms seldom subside definitively before the third, fourth, and not 
unfrequently the fifth day. In no case that has come under our observa- 
tion, has the disease continued to present dangerous symptoms after the 
fifth day, unless, as not unfrequently happens, the inflammation spreads to 
the bronchia or tissue of the lungs, producing bronchitis or pneumonia. 
But even after the signs of severe laryngeal inflammation have disap- 
peared, there almost always remains for several days longer, some cough 



II 
I 



NATURE OF THE DISEASE. 73 

and hiiskiness of the voice, marking that the mucous membrane of the 
larynx has not yet regained completely its healthy condition. The disease 
is said to have proved tatal in twenty-four hours. 

Nature of the Disease. — Authors hold very different opinions as to 
the nature of spasmodic laryngitis. By Underwood, Dewees, and Eberle, 
it is confounded with membranous laryngitis, they making no distinction 
between false or catarrhal, and true or membranous croup. Dr. Cheyne 
(Cyclop. P}'act. Med., Art. Croup) treats of the two affections as one and 
the same disease, differing only in their degree of violence. Dr. Copland 
(Diet, of Pract. Med., Art. Croup) describes spasmodic croup as a variety 
or modification of true or membranous croup. He supposes that the modi- 
fications of true croup are attributable to " the particular part of the air- 
passages chiefly aftected, to the temperament and habit of body of the 
patient, and the intensity of the causes." It seems to us, however, that 
these views as to the nature of the two diseases are not correct, and we are 
induced by personal observation to regard them as distinct affections, which 
may, in the great majority of cases, be distinguished from each other at a 
very early stage, by a careful observer. The comparative fatality of the 
two diseases alone is sufficient to establish a wide difference between them. 
Thus, of 35 cases of the pseudo-membranous form that we have seen, 16 
died ; while of considerably more than 200 cases of the spasmodic form 
that we have seen, not one has been fatal. M. Guersent states that of ten 
cases of the former disease, scarcely two escape ; while of upwards of a 
hundred of the latter that he has seen, not a single one was fatal. {Diet. 
de Med., t. ix, p. 365.) 

The different effects of treatment in the two affections also point to a 
wide difference in their nature. True croup is almost inevitably fatal, un- 
less attacked at an early period by energetic remedies, while the mild spas- 
modic form seldom resists the exhibition of an emetic, a warm bath, or of 
nauseating doses of ipecacuanha or antimony ; and the severe form, though 
of a most threatening appearance, almost always yields to the proper em- 
ployment of very moderate local depletion, aided by the use of expector- 
ants, emetics, opiates, and correct hygienic means. When we add to these 
circumstances, the differences in the anatomical alterations in the two dis- 
eases, the difference in the mode of invasion, in the cough, voice, cry, fever, 
duration of the attack, and state of the constitution, all of which will be 
carefully described in the remarks on diagnosis, we do not see how we can 
resist the conclusion that they are two distinct disorders, and not, as was 
formerly generally asserted by English writers, degrees or modifications of 
the same. 

We believe, therefore, that mild spasmodic laryngitis is a disease con- 
sisting in slight catarrhal inflammation of the mucous membrane of the 
lar}'nx, attended with violent spasmodic contraction of that organ, or, as 
that condition has been called of late, laryngismus. The spasm of the 
laryngeal sphincter seems to be the result of a disordered action of the 
exfito-motor innervation of the part, the irritiint, which is j)roductive of 
the morbid innervation, being, in all probability, the inflammation of the 
lar}'ngeal mucous membrane, which has been already stated to constitute 



74 SPASMODIC SIMPLE LARYNGITIS. 

one element of the malady. The nervous element predominates in the early 
part of the attack, but towards the conclusion, the spasmodic symptoms 
disappear entirely, and we have left only those which depend on the local 
tissue-changes. 

In severe cases of the disease we have the same element of laryngeal 
spasm, or laryngismus, coincident with, and produced by, a much more in- 
tense and dangerous inflammation of the mucous membrane of the part 
than exists in the mild form. 

Diagnosis. — Unquestionably the disease with which spasmodic laryn- 
gitis is most likely to be confounded is pseudo-membranous laryngitis, or 
true croup. There is very little difficulty, however, in distinguishing the 
mild form of spasmodic croup from true croup, whilst in regard to the 
severe form, it may be safely stated, that the distinction cannot, in some 
cases, be made with positive certainty, except by watching the course of the 
sickness. 

Mild cases of spasmodic croup may be distinguished from membranous 
croup by a comparison of the different symptoms as they arise. The most 
important of these are : the invasion, in one sudden and almost invariably 
in the evening or night, in the other slow and creeping, the paroxysm first 
occurring indifferently day or night ; the cough, in one hoarse and boister- 
ous, in the other hoarse and frequent at first, but rare and smothered to- 
wards the end ; the voice, in one hoarse, but never scarcely whispering, 
and if so, only during the height of the paroxysm, in the other hoarse at 
first, and soon permanently whispering or entirely lost ; the cry, in one 
hoarse and stridulous only at the moment of the paroxysm, in the other per- 
mianently so ; the respiration, in one stridulous and difficult only during the 
paroxysm, and in the interval perfectly natural, in the other, at first natu- 
ral, becoming by degrees permanently stridulous, and attended by the most 
violent dyspnoea, with remarkable prolongation of the expiration, and even 
with recession of the base of the thorax in inspiration ; the fever, in one 
very slight and generally observed only during the nocturnal paroxysm, in 
the other much more considerable and permanent ; and lastly, the duration, 
in one seldom more than two or three days, in the other rarely less than 
six, and very often eight or ten days. M. Trousseau states that the hoarse- 
sounding croupal cough is not a sign of the presence of exudation in the 
larynx, but rather of its absence ; but, " when the cough, croupal at first, 
becomes less and less frequent, and ends with being nearly insonorous with 
suffocation, there is true croup, that is to say, with plastic exudation in 
the larynx." This is precisely our own experience. The rare, insonorous 
cough of M. Trousseau is the condition which we have expressed by the 
term smothered. 

In order to render the diagnosis still clearer, we add the following 
table, which is altered from one given by MM. Rilliet and Barthez : 

MILD SrASMODIC LARYNGITIS. PSEUDO-MEMBRANOUS LARYNGITIS. 

Begins with coryza and hoarse cough, In epidemic form, begins as pseudo- 
or more frequently with a sudden attack membranous angina. In sporadic form, 
of suffocation in the night. Eauces natu- invasion of slight hoarseness for a day 



DIAGNOSIS. 75 

MILD SPASMODIC LARYNGITIS. PSEUDO-MEMBRANOUS I. ARYiTGITIS. 

ral, or merely slisjht redness, as in simple or two. There is fever, inoroaso of the 
angina. hoarseness, with hoarse, croupal coui;h ; 

in most of the cases, pharvniroal exu- 
dation, and a little later, paroxysms of 
suffocation. 
Afterthe paroxysm, thechildseems well, The fever continues; stridulous res- 
the fevfr disappears, or is very slight, piration ; prolonged and difficult expi- 
Voice natural, or only slightly hoarse ; not ration; recession of base of thorax 
whispering. during inspiration ; cough hoarse and 

smothered ; voice hoarse and wliisper- 

inir. 

If the paroxysm returns, it is during the The dyspnoea and suffocation increase; 

following ni^ht, and it is less severe; the the voice and cough are smothered or 

hoarseness disappears ; the cough becomes extinguished; stridulous respiration 

loose and catarrhal. persists. 

Duration seldom more than three days. Duration seldom less than five or six 

days. The hoarseness continues for 
several weeks. 
Very rarely fatal. Fatal in the majority of the cases. 

The only real difficulty in the diagnosis is the distinction between the 
grave form and pseudo-membranous laryngitis or true croup unconnected 
with angina ; and this, it would appear from all evidence, cannot in some 
cases be made with absolute certainty. The only certain and indubitable 
sign by which to distinguish them is the presence of false membranes in 
the ex|>ectoration. The existence of this symptom is proof positive of 
pseudo-membranous disease, but its absence is no proof that the case must 
be one of simple inflammation ; for, even though the membrane has been 
exuded in large quantities within the larynx, it is not always thrown off 
by the effort of coughing or vomiting. To show the difficulty of the diag- 
nosis, we will cite the case quoted by M. Valleix {loc. cit., t. i, p. 211) from 
M. Hache, of a child supposed to be laboring under true croup, who was 
sent to the Children's Hospital in Paris, in order to have the operation of 
trachtN)tomy performed. The ab.sence of false membrane in the expecto- 
ration, and a slight remainder of clearness in the voice, occasioned the 
9US|>en8ion of the operation. The child died, and no pseudo membrane 
whatever was found in the larynx. The only lesions were moderate red- 
ness of the mucous membrane, without tumefaction, and without narrow- 
ing of the glottis; so that the fatal termination must be a.scribed to spas- 
modic constriction of the glottis, or to tumefaction of that part, which had 
di.«appeared after death. 

Nevertheles"*, though the diagnosis is difficult, it can almost always be 
made out with certainty by attention to the following points. The pseudo- 
membranous form of the di.sca.se is usually preceded or accompanied by 
the presence of false membranes in the fauces, which is not the case in 
spasmodic simple laryngitis; the symptoms of invasion of the former dis- 
ease are less acute than those of the latter, the fever being less violent, and 
the restlessness and irritability less marked, than is usual in the simple 
affection, in which the general symptoms are decided fVom the first. The 
hoarseness of the voice and cough follow a different course in the two dis- 



76 SPASMODIC SIMPLE LARYNGITIS. 

eases ; the progress of these symptoms being slow and gradual in the mem- 
branous, and much more rapid in the severe spasmodic form. The fever 
is marked throughout the attack in the severe spasmodic disease, whilst in 
the other form it seldom reaches a high degree of intensity. Lastly, the 
presence of portions of false membrane in the expectoration, in connection 
with the laryngeal symptoms, affords positive evidence of the existence of 
true croup. 

Of the characters just enumerated as likely to aid us in distinguishing 
between severe spasmodic and true or membranous croup, we wish to call 
the reader's attention in greater detail to two, — the condition of the voice, 
and the stridulous respiration. The former is, we have no doubt, much 
the most important single symptom. In membranous croup, the voice 
begins by being hoarse, but soon becomes weak, so that after the disease 
has lasted three or four days, it changes from hoarse to whispering; it be- 
comes, in fact, suppressed. In severe spasmodic croup, the voice is hoarse 
at first, and becomes more so as the disease goes on, but it very rarely be- 
comes whispering as in true croup, but almost always retains a good vol- 
ume, so that when urged the child can speak out loudly. Now this is 
never the case in the membranous disease, for, as the fibrinous exudation 
is deposited on the vocal cords and in the ventricles of the larynx, it sus- 
pends almost entirely the functions of those parts, and the voice is more or 
less completely suppressed. The remarks just made in regard to the voice 
will apply also to the cry, which should be carefully studied in young 
infants. 

The second very important symptom is the stridor. This is, as might 
be expected, more marked in all its features in true than in false croup, 
since in the former it depends on a permanent and considerable obstacle 
to the passage of the air through the larynx. That tube is, in fact, com- 
pletely coated over upon its internal surface, with a more or less thick 
false membrane, which reduces, materially its calibre, and impedes to a 
greater extent the passage of air, than does the mere inflammatory tur- 
gescence and swelling of the mucous membrane of the organ in severe 
spasmodic croup. On this account, therefore, the stridor in the respira- 
tion is louder, shriller, more persistent, more marked in the expiration, 
and attended with greater effort of the respiratory muscles to overcome 
the obstacle to the passage of the air in membranous than in severe spas- 
modic croup. We may add that there is something very peculiar in the 
cough in true croup. When the membrane has come to cover the in- 
terior of the larynx, the cough is very distinctive ; it has a sound which 
we can describe only by saying that it always reminds us of the sneezing 
of a young kitten. This we have never heard in catarrhal croup, no 
matter how severe. 

To conclude, there is in membranous croup a slow, steady, and unre- 
lenting progression of the symptoms, which is not observed in the spas- 
modic disease. From hour to hour, from day to day, we can perceive, so 
to speak, from the gradual and steady march of the disease, that a foreign 
body in the form of a fibrinous moulding is being spread slowly over the 
cavity of the larynx. In severe spasmodic croup, on the contrary, the 



TREATMENT. 77 

course of the symptoms is less regular ; paroxysms of suftbcatiou occur as 
in true croup, but when these are over, the child is ofteu quite comfort- 
able ; the symptoms imiicatiug a much less cousiderable permaueut me- 
chanical obstruction than in the other affection. 

Spasmodic laryngitis has been mistaken also for laryngismus stridulus. 
The manner in which it is to be distinguished, will be described in the 
article on that disease. 

Prck»nosis. — Spasmodic catarrhal laryngitis is very rarely a fatal dis- 
ease. Of its two forms, there can be no doubt that the severe is much 
more dangerous thau the mild, since in the former the patient labors 
under acute intlammation of the larynx, as well as under spasm of that 
organ ; whilst, in the latter, the amount of inflammation is so very slight 
as to be of little or no consequence, were it not associated WMth the laryn- 
gismus, which gives to the disorder its most characteristic features. 

Of 109 cases of the disease of which we have kept an accurate record, 
Done proved fatal, though 23 of these were of the grave form. We may 
state, also, that we have seen at least 100 more cases, of which we have 
no written account, in none of which was there a fatal termination. We 
have, therefore, never seen a case of croup without false membrane prove 
fatal. That it does sometimes end unfavorably, however, cannot for a 
moment be questioned. There are various examples of the kind scattered 
through the medical journals. M^NI. Rilliet and Barthez quote, in proof 
of this, two cases from the work of Jurine, in one of which an autopsy 
was made, and no false membrane discovered. Copland {loc. cit.) re- 
marks, that in the few cases of the more purely spasmodic forms that he 
has had an opportunity of examining, an adhesive glairy fluid, with 
patches of vascularity on the epiglottis and larynx, and a similar fluid in 
the large bronchi, were the only alterations observed. 

Great imminence of danger in any case is shown by a high intensity 
of the gtridulous sound, especially as heard in the expiration ; by great 
severity of the dyspncea or suffocation ; by permanently whispering voice; 
by lividity or extreme paleness of the face; by smallness and rapidity 
of the pulse; by coldness of the extremities ; and by delirium or convul- 
sions. 

Treatmext. — M. Guersent (loc. ciL, pp. 367, 368) states that demul- 
cent and mucilaginous drinks, with stimulating hand-baths and foot- 
baths, are the principal means that ought to be employed in the treat- 
ment of spa.«modic laryngitis, or pseudo-croup. He proscribes the use of 
emetio; and leeches as unnecessary in most cases, and is of opinion that 
they have come into general use, in the management of the disease, in 
consequence of its having been generally confounded with true croup. 
In a paper on croup, by the late Dr. Charles D. Meigs (^ff.'d. Exam., vol. 
i, p. 308;, may be found the following statement in regard to the spas- 
modic variety: "The croup sound often ceases entirely, and never returns 
afler the exhibition of a small quantity of ipecacuanha, or any other 
emetic substance, even when no emcisis is prcxluced." He says in another 
place, that " a foot-bath with mustard, and an emetic of ipecacuanha, is 
in general all thnt is nfffs-ary for the cure." 



78 SPASMODIC SIMPLE LARYNGITIS. 

In giving our own experience in regard to the treatment of this disease, 
we shall speak first exclusively of the mild, and then of the severe form, 
since the measures proper and necessary in the one, are very dijfferent 
from those called for in the other. 

Treatment of the Mild Form — Emetics. — The great majority of 
cases will recover perfectly well under the use of emetics employed alone, 
or in combination with warm baths and revulsives. Of late years we 
have often succeeded in warding off the slight attack, where there has 
been good reason to expect it, by the administration of an opiate with 
syrup of ipecacuanha, at bedtime (early in the evening). At two years 
of age, three or four drops of laudanum, with ten to twenty drops (ac- 
cording to the gastric susceptibility) of syrup of ipecacuanha; at three or 
four years, five drops of laudanum with twenty of the ipecacuanha, are 
about the proper doses. Even when the child has had one attack early 
in the night, the use of the opiate is most successful, after vomiting, in 
preventing the usual return towards morning. If the physician is not 
called until the day after the first attack, this treatment is excellent in 
the evening of the second day. In cases attended with violent dyspnoea, 
hoarse cough, and loud stridulous respiration, the emetic should be given 
until it produces a full effect. In milder cases, in which there is merely 
loud croupal cough, with an occasional stridulous sound, nauseating doses 
alone will generally suffice. The most suitable emetic is, as a general 
rule, ipecacuanha. The best preparation for children is the syrup, of 
which from twenty to thirty drops may be given to those two years of age, 
to be repeated every ten or twenty minutes until vomiting is produced, or 
until the paroxysm is relieved. In very sudden cases, the Syrupus Scillse 
Compositus, which is more active in its effects in consequence of the tartar 
emetic which it contains, might be preferable ; about twenty drops of this 
may be given, and repeated every ten or fifteen minutes, until vomiting or 
the resolution of the paroxysm is obtained ; but, in its employment, care 
should always be observed not to continue it for too long a time, lest it 
produce the injurious effects of tartar emetic. Of late years we have 
almost entirely abandoned the use of this latter emetic, as we succeed per- 
fectly well with the ipecacuanha, and dislike more and more the antimo- 
nial preparation in children. When the dyspnoea is very urgent, or when 
other means fail to produce emesis, we have found nothing so efl^ectual as 
powdered alum, in doses of a teaspoonful mixed with honey or molasses. 
(See Treatment of Pseudo-membranous Laryngitis.) 

A simple and good method of treating the paroxysm is that recom- 
mended by Dr. Charles D. Meigs, in the paper referred to. It is to direct 
a small teaspoonful of powdered ipecacuanha to be diffused in a wine- 
glassful of water, of which mixture doses of a teaspoonful are to be given 
every ten, fifteen, or twenty minutes, according to the urgency of the 
symptoms. This is a plan of treatment often resorted to by parents in 
this community, where the disease is so common and so well understood, 
that there are few mothers who have several children, and who have had 
some little experience, who do not know how to treat a nocturnal attack of 
mild spasmodic laryngitis. 



I 



I 



TREATMENT. 79 

A very simple and efficient mode of treating tlie paroxysm, which was 
first recommended by Graves, consists in gently pressing a sponge soaked 
in warm water under the chin and to the front of the neck. This may be 
repeated every ten or fifteen minutes, and under its influence the croupy 
sympioms will often promptly subside without the use of an emetic. 

After the paroxysm is relieved, it is a good plan to direct five or ten drops 
of the ipecacuanha syrup to be given every two or three hours during the 
following day; or, if the child seems perfectly well in the morning, we 
may begin with these doses in the middle of the day, and continue them 
until bedtime. By this method, the recurrence of the paroxysm during 
the second night may, we think, often be prevented, and the cough is ren- 
dered free and loose much sooner than when the disorder is left to pursue 
its natural course. Moreover, the child ought to be kept in the house dur- 
ing the next two or three days, or until the cough is thoroughly loose and 
easy. If the child be at all a delicate one, or one in whom the disorder 
is prone to be obstinate, there is no plan so good as to make it sit or lie 
quietly in bed, sufficiently covered, with a large abundance of playthings, 
or with a kind nurse to read to and amuse it for two or three days. 

Baths. — The warm bath is a very prompt and useful remedy in the dis- 
ease. In all very violent cases, it ought to be resorted to immediately. It 
should be used also whenever the emetic fails to relieve the urgency of the 
symptoms, and in cases attendant with much disturbance of the circula- 
tion. The temperature of the water ought to be about 95° Fahrenheit, 
when the child is first immersed, to be raised gradually by the addition of 
hot water, to 100° or 102°. The child may remain in the bath from ten 
to twenty minutes. 

B€vnL'*ive-!<. — The only revulsives that it can be necessary to employ are 
mustard foot-baths or mustard poultices applied to the interscapular space ; 
and even these are often needless if the emetic be given. Blisters, which 
are recommended by some of the French writers, can only be proper in 
rare cases of the grave form. 

Purgatives are required when constipation is present, or when there is so 
much fever on the second or third day, as to show a considerable amount 
of lar}'ngeal inflammation. Under the latter circumstances .some mild 
remeiiy of this class may be resorted to with a view to its evacuant efil^ct. 
We have never had occasion to employ any of the mercurials^ and believe 
them to be unnecessar)'. 

Opium is exceedingly beneficial when the emetic, nauseant, or warm 
bath has failed to relieve entirely, and when a troublesome croupal cough 
continues after the spasm has been overcome. Laudanum, paregoric, or 
solution of morphia, in combination with syrup of ipecacuanha or Dover's 
powder alone, are the most suitable preparations. It is a very good plan 
to give the child a moderately full dose of the opiate, with ipecacuanha, 
after the violence of the paroxysm has subsided. It puts the child to 
sleep, promotes perspiration, softens the cough, and tends to prevent the 
return of the spasm. Repeated once or twice early in the second night 
after the first attack, we believe it often assists materially to avert the 
recurring nocturnal paroxysm. 



80 



SPASMODIC SIMPLE LARYNGITIS. 



Treatment of the Severe Form. — This form of spasmodic laryn- 
gitis requires more active measures than the mild form of the disease. 

In some of the former editions of this work, bloodletting was recom- 
mended when the disorder occurred in robust and vigorous children, and 
a record was given of the employment of venesection in seven out of 
twenty-three cases, all of which recovered. Since that report we have 
learned that depletion is less necessary than we formerly supposed, and, 
as we can still say that we have never yet seen a fatal case of spasmodic 
croup, either simple or severe, it is fair to conclude that the disease can be 
safely managed without a resort to this more violent measure. Still, it is 
but proper to state, that should a case occur to us in a strong and healthy 
child, in which the breathing should become so much obstructed as to 
cause deep and alarming venous stasis, and in which these symptoms re- 
sisted the more simple means we now employ, we should not hesitate 
again, as in former years, to employ a venesection to the extent of four 
ounces at the age of four or five years, or a leeching to the same amount. 

Our favorite remedies of late years have been emetics, opiates, salines, 
and the sulphurated antimony of the recent Pharmacopoeia. When the 
patient is a vigorous child, and over a year old, we generally employ the 
following combination : 



R. — Antimon. Sulphurat., 
Pulv. Doveri, . 
Sacch. Alb., 

M. et div. in chart, xij. 



gr. J. 
gr. iij. 
gr. xij. 



i 



Of these powders one may be given every two, three, or four hours, care 
being taken to suspend the antimony when it produces any of the peculiar 
distress or general prostration to be described in the article on pneumonia. 
In such a case, we use one of the following combinations : 



Or 



.—Potass. Citrat., . 


• . . . 3J- 


Syrup Ipecacuanhae, . 


. . . . fgij- 


Tr. Opii Deodorat., . 


. . . . gtt. xij. 


Syrup Simp., 


.... f^ij. 


Aq, 


. f^iss.— M. 


Dose for a child two years old, 


a teaspoon ful every two hours. 


. — Aramonife Muriatis, 


gr. xxiv. 


Ammonii Bromidi, 


3J- 


Syrup Ipecacuanhae, 


fgiss. 


Syrup Zingiberis, . 


fk'js^^- 


Aquae, .... 


f^iss. 



Ft. sol. Dose for a child two years old, a teaspoonful every four hours. 



In older children, both the potash and opiate may be doubled. In all 
these cases an emetic ought to be given once, or two or three times in 
twenty-four hours, when the dyspnoea and stridor become very severe ; and 
in about an hour after its operation, the saline dose should be resumed. 
Of course, if decided drowsiness supervene from the opiate, the doses must 



TREATMENT. 81 

be given at longer intervals. The emetic treatment is not so essential as 
in true croup, where it is so useful in causing the rejection of the false mem- 
brane which obstructs the larynx. Yet it is exceedingly useful, and often 
indispensable, in assisting to expel the viscid mucus secreted within the 
larynx, and in relaxing, for a time at least, the spasmodic constriction of 
the glottis, which plays a most important part in the production of the 
distre^iug dyspnwa and suffocation of the disease. They act probably also 
by lessening immeiiiately, or through their action on the circulatory and 
nervous systems, the inflammation of the larynx. For their choice and 
mode of administration, the reader is referred to the article on true croup. 

Purgatives are required merely to keep the bowels soluble ; they should 
be repeated as may be neces^sary throughout the disease. If the bowels 
are moved every day or every other day spontaneously, there is no use in 
giving them at all. The most suitable are castor oil, rhubarb, or magnesia, 
in small doses ; or an enema may be given from time to time if the child 
does not resist its application. 

Expectorants are useful after the violence of the disease has been mod- 
erated by more energetic remedies. They may consist of small doses of 
ipecacuanha, of antimonial wine and sweet spirits of nitre, of decoction 
of seneka, snakeroot, or of the citrate or carbonate of potash. 

Opiates are necessary, and are serviceable, as has already been stated, 
in calming excessive restlessness, and in allaying the violence of the suffo- 
cative attacks, which depend, in good part, on spasm of the glottis. The 
most suitable are Dover's powder or some other preparation of opium, or 
small doses of belladonna, or hyoscyamus. 

Belladonna would seem, from its power to relax the sphincters, and from 
ita excellent effects in hooping-cough, to be indicated in this disease, but 
we have succeeded so well with opium that we have not often used bella- 
donna. Probably a combination of the two would be found beneficial. 

A warm bath at 97° or 98°, employed once or twice a day, and continued 
for a period of ten or fifteen minutes, often assists greatly in lessening the 
sufferings of the child, in calming restlessness, and in moderating the heat of 
skin, and violence of the circulation, when the latter symptoms are strongly 
marked. The same effects may often be obtained by the use of counter- 
irritants, as sinapisms, mustard poultices, mustard foot-baths, etc. Blisters 
are of doubtful propriety in any cases. 

Hygienic Tkeatmknt.— In either form of the disease the child should 
be placed for the time in a warm room, and warmly clothed. If old enough, 
it ought to be kept as much as possible in bed during the paroxysm. If 
so young as to prefer the lap of the nurse, it should be clothed in a long 
loose wrapper in addition to its usual night-dress. It is very important to 
confine the child during the whole term of the acute period in the bed, if 
it is over three or four years old, and in the crib or lap if it be younger. 
Even after the cessation of the acute condition, it ought to be kept in the 
house for a few days, in order to make sure of the convalescence. The 
diet must be simple and of easy digestion, so long as there is any disposi- 
tion to recurrence of the disease. It may consist of preparations of milk, 

6 



82 SPASMODIC SIMPLE LARYNGITIS. 

of bread, rice, or of thin chicken or mutton water. Meat and most vege- 
tables had better be avoided until the convalescence is fairly established. 

Prophylactic Treatment. — It is certain that much may be done by 
a wise attention to physical education, to prevent attacks of the disease in 
children who show a liability to it. We would strongly recommend, with 
this view, attention to the following advice given by M. Guersent, who says 
(Jog. cit., p. 381) : " It is possible, to a certain extent, to prevent attacks 
of pseudo-croup, if we fortify the constitutions of children, by exposing 
them well-clothed to a dry and elastic atmosphere, particularly if they can 
be kept in constant movement. But of all the precautions which have 
been found unquestionably advantageous, that which seems most useful is 
to make them sleep in well-ventilated, dry, carefully closed chambers, 
having a southern exposure, and always without fire. We have several 
times been convinced of the utility of this habit in families the children 
of which were subject to this kind of catarrh." 

There can be no doubt that the style of dress used for children in this 
country, must occasion many and repeated attacks of croup which might 
just as well have been avoided. The custom is to dress children between 
the ages of one and four or five years, in such a way as to expose to the 
air the whole of the neck and the upper half of the thorax (for the dresses 
are made so low and loose at the shoulders, as to leave the upper part of 
the chest virtually uncovered). The arms are left bare, as are also the legs 
from the knee, or above the knee, to the ankle, so that very nearly half of 
the cutaneous surface is without covering, and this too, in the very same 
rooms and temperature in which sit the parents with the body and limbs 
warmly clothed to resist our climate, at all seasons changeable and uncer- 
tain, and, in the winter, very cold. We are perfectly well convinced that 
this faulty and unreasonable system of dress, which is chosen because it is 
the fashion, or in order to harden the child, who, however, invariably puts 
on warm clothing when it comes to years of discretion, will explain in part 
the enormously greater frequency in children than in adults, of the various 
diseases of the air-passages and lungs produced by cold. 

One of the most important means of prevention, therefore, is the adop- 
tion of a suitable dress. In winter this should consist of one that shall 
cover the body completely. If the child be at all delicate, it ought to 
wear next to the skin a woollen jacket with long sleeves, and covering the 
chest to the neck. Over this should be put a long-sleeved stout muslin 
dress, or one of some light woollen material, made in the same style. In 
young children, the stockings ought to be of wool, and should reach to the 
knees ; in older ones, they may be shorter, but the legs should be covered 
■with drawers made of canton flannel, of thick cotton stuff, or of light 
woollen flannel. To show the influence of dress. Dr. Eberle mentions the 
fact that in the country, and especially amongst the Germans, who cover 
the neck and breast, croup is a very rare disease. During a practice of 
six years amongst that class of people, he met with only one case of the 
disease. 

When the liability to the disease continues after the completion of the 
first dentition, we have found the daily use of the cold bath, in connection 



NATURE AND RELATIONS. 83 

always with warm clothing, most useful in preventing the attacks. The 
bath must be commenced with in the summer, and persevered in through 
the following winter. The water, after the cold weather begins, should be 
drawn in the evening, allowed to stand all night in a room in which there 
is a fire tlirough the day, and made use of on the following day. Prepared 
in this way, we have found the water in the morning at a temperature of 
between 50^ and 60° F. The child ought to be kept in the water only 
half a minute or a minute, then well rubbed, and dressed immediately. 

When the child is pale, weak, and feeble, and unable to bear exposure 
to the outer air, it may generally be restored to much better health by 
careful attention to diet, and by the steady and long-continued use of 
some tonic remedy. The diet ought to consist of bread and milk, and of 
meat and the simpler vegetables, as potatoes and rice. The tonics most 
generally suitable are quinine or iron. Of the quinine a grain may be 
given in pill or solution, twice or three times a day ; while at dinner or 
lunch, or at both, the child should be made to drink from a dessert to a 
tablespoonful of port wine, mixed with water. This method ought to be 
steadily persevered in for from three to six weeks or longer. If quinine 
be objectionable for any reason, iron must be substituted. The best prep- 
arations are the iodide or the metallic iron. 



ARTICLE III. 

PSEUDO-MEMBRANOUS LARYNGITIS, OR MEMBRANOUS OR TRUE CROUP. 

Definition and Synonyms. — Pseudo-membranous laryngitis is an 
acute inflammation of the mucous membrane of the larynx, attended with 
the exudation of false membrane. 

It ia the croup of the French writers, while, in this country, it is called 
by the various names of slow, creeping, true, membranous or iuflamma- 
tor}'. The terra given above seems most suitable, as expressive of the real 
nature and seat of the disease, and we shall, therefore, make use of it in 
contradistinction to that of spasmodic laryngitis or spasmodic or false 
croup, which is a much more common and less dangerous affection. 

Natike and Relations. — Since the publication of our last edition, 
the questions of the es-sential nature of membranous croup and its rela- 
tions with diphtheria have been actively discussed, and it has appeared 
that there are marked differences in the opinions held by the best authori- 
ties. In the present state of the discussion, it is iniproper to attempt any 
dogmatic assertions on the points at issue, but it seems desirable to restate 
fully the views we have long held and the considerations on which they 
are based. By many authorities, true croup is regarded as an ifliopathic 
primary inflammation, presenting the unusual result of pscudo -membra- 
nous exudation, and differing thus from diphtheritic crou]), which is a 



84 PSEUDO-MEMBRANOUS LARYNGITIS. 

mere complication in the course of a constitutional disease, depending 
upon the extension of the false membrane from the fauces into the larynx. 

The considerations upon which this distinction is based may be briefly 
stated as follows : that true croup is a disease peculiar to childhood, and 
that many of its peculiarities are to be explained by reference to the de- 
velopment of the larynx at that period ; that it is a local disease and not 
connected with any special alteration of the blood crasis ; that it is not 
contagious ; that it nearly always commences in the larynx, and, though it 
may pass downwards into the trachea, never passes upwards into the 
pharynx ; and finally, that it does not present the complications of diph- 
theria, such as albuminuria and pseudo-membranous exudation on abraded 
surfaces, nor its characteristic paralytic sequelae. 

So far as the mere anatomical conditions are concerned, it is generally 
conceded that there is no essential difference between primary croup and 
pseudo-membranous croup occurring in the course of diphtheria. The 
attempt was made by M. Isambert to base a distinction between the two 
affections upon the ulcerated condition of the mucous membrane of the 
larynx in diphtheritic croup, but West has met with similar ulceration in 
cases of primary croup, though somewhat less frequently than in the sec- 
ondary diphtheritic form. 

It has also been attempted to establish a distinction between the morbid 
process in croup and in diphtheria upon the greater intensity of the lesion 
in the latter case, associated with more swelling, a more intense congestion 
of the mucous membrane ; but from careful observation of the numerous 
grades of severity of the diphtheritic process, we are convinced that this 
difference in degree is not constant, and cannot be made the basis of a 
radical division of the two affections. It appears moreover that there is 
no essential chemical or histological difference between the pseudo-mem- 
branes formed in the two conditions. 

But further, our personal experience constrains us to state that the dif- 
ferences between the two forms of membranous croup above enumerated, 
have not seemed to us sufficiently marked and constant to positively estab- 
lish their essential diversity ; and that it is our decided opinion that the 
vast majority, of the cases usually termed pseudo-membranous laryngitis 
are in reality instances of primary laryngeal diphtheria, in which the con- 
stitutional symptoms are not grave, and where the faucial deposit has been 
very slight and perhaps even overlooked. 

We are led to this conviction especially by the repeated observation of 
cases in private practice, where we have been summoned upon the first 
symptoms of indisposition, and have found a trifling amount of membran- 
ous exudation on the fauces, which, in a day or two, had disappeared, while 
the symptoms of croup supervened. In one of the most recent works on 
General Pathology, Wagner, who inclines to believe in the distinction be- 
tween the two affections, says (p. 266), " in the greater number of fatal 
cases of laryngeal croup, diphtheritic exudation is found on the soft pal- 
ate." 

Apart from their sporadic occurrence, we confess that we are altogether 
unable to detect any difference between such cases and the cases of so-called 



NATURE AND RELATIONS. 85 

primary laryngeal diphtheria, frequently met with in epidemics of diph- 
theria, where the angina is but trifliug, and is rapidly followed by pseudo- 
membranous formation in the larynx. 

It is true that the primary sporadic form of croup we are now discussing 
occurs more exclusively in children than does the more fully developed 
form of diphtheria ; but it must be remembered that in childhood there 
seems to be a peculiar tendency for the larynx to become involved in the 
course of diphtheria, and also that a comparatively trifliug amount of 
membranous exudation in a child's larynx will produce grave symptoms 
of obstruction. 

It is true that in membranous croup there is but little enlargement of 
the lymphatic glands, but when the anatomical conditions of the larynx is 
borne in mind it will be understood why there should be but little lym- 
phatic implication, while, when the pharynx with its very rich lymphatic 
supply is affected, enlargement of the glands is a prominent symptom from 
an early date. We may here merely allude to the query whether this 
latter fact may be concerned at all in more frequent constitutional infec- 
tion which follows pharyngeal diphtheria. 

It is also true that these sporadic cases are rarely attended with albu- 
minuria or followed by paralytic sequelce ; but when we consider the re- 
markable variations in the frequency of these conditions in different epi- 
demics of diphtheria, it is not inconsistent that they should be usually 
absent in mild sporadic cases. 

In regard to the difference in the contagiousness of croup and diph- 
theria we would merely remark, that it is undoubted that in cases where 
the virulence of the disease is marked, and where its infectious or conta- 
gious character is most pronounced, the pseudo-membrane is most likely to 
appear first in the pharynx, and to be extensive and persistent. On the 
other hand, in ca:?es where the infectious character is but slightly devel- 
oped, and the symptoms mild, the membrane either remains limited to the 
pharynx where it speedily disappears, constituting the mild cases of diph- 
theria which we frequently meet with, usually in a sporadic form. Or, in 
a certain proportion of these cases, the pharyngeal deposit having been 
slight and often overlooked, the larynx is invaded and the symptoms of 
membranous croup appear. It is but natural, if this suggestion be entitled 
to any weight, that there should be found a considerable diflference in the 
degree of contagiousne^ of croup and of grave infectious diphtheria. 
However, we have recently met with two separate instances where among 
children of a family, one was seized with membranous croup presenting 
the symptoms and course described in the sporadic idiopathic form, while 
one or more of the others were affected with pharyngeal diphtheria. 

As we have above stated this question must be regarded as still under 
discussion and un.settled. We are by no means prepared to assert the 
identity of croup and diphtheria in all case,**, but have merely desired to 
state the considerations which incline us to regard them as closely allied, 
and as probably being different forms of one great pathological process. 

As it is not our intention, therefore, to deny the possibility of pseudo- 
membranous larj'ngitis occurring as a purely primary idiopathic affJection, 



86 



PSEUDO-MEMBRANOUS LARYNGITIS. 



we have consequently treated of it as a special disease, apart from the brief 
notice of it we have given in the article on diphtheria. 

But the considerations which we wish to impress deeply upon the mind 
of the reader are, that in the vast majority of cases of true croup careful 
examination of the throat at an early period of the attack will show the 
presence of exudation on the tonsils or pharynx ; and that, consequently, 
whenever a child is taken sick with even the most trifling croupy symp- 
toms, the throat should be immediately and repeatedly examined, and, if 
any membranous exudation be detected, the case should be regarded as 
probably one of membranous croup, a most guarded prognosis accordingly 
given, and the most careful treatment immediately instituted. 

Frequency. — The mortality from this disease is in all years consider- 
able, as will be seen from the subjoined table: 





Mortality 






Mortality 


Total Mortality 


Years. 


from Croup. from Diphtheria. 


less Stillborn. 


1846, 


. - . Ill . . . 


. 5,944 


1847, 


. 121 









. 6,881 


1848, 


. 177 






. 


. 7,268 


1849, 


. 130 









. 8,989 


1850, 


. 151 









. 8,034 


1851, 


. 180 









. 8,374 


1852, 


. 208 









. 9,745 


1853, 


. 303 









. 9,184 


1854, 


. 304 









. 11,280 


1855, 


. 265 









. 9,906 


1856, 


. 268 









. 11,720 


1857, 


. 256 









10,331 


1858, 


. 292 









10,162 


1859, 


. 312 









9,084 


1860, 


. 354 






307 


10,849 


1861, 


. 304 






602 


13,838 


1862, 


. 258 






825 


14,386 


1863, 


. 443 






434 


15,045 


1864, 


. 455 






357 


16,794 


1865, 


. 350 






260 


. 16,453 


1866, 


. 239 






192 


16,005 


1867, 


. 185 






118 


13,153 


1868, 


. 206 






118 


13,949 


1869, 


. 237 






182 


13,428 


1870, 


. 316 






172 


15,317 


1871, . . . 


. 264 






145 


15,485 


1872, 


. 296 






150 


18,987 


1873, 


. 200 






110 .. . 


15,224 


1874, 


. 199 






179 


16,238 


1875, 


. 428 






656 .. . 


17,805 



It is difficult to estimate the number of deaths due to this affection since 
diphtheria has made its appearance in the mortality lists of the city, as 
many cases of diphtheritic croup have unquestionably been returned as 
mere pseudo-membranous laryngitis. 

True croup is, however, rare in comparison with false croup, since while 
we have seen but 35 cases of pseudo-membranous laryngitis, we have met 



PREDISPOSING CAUSES. 87 

'with upwards of 200 of the catarrhal form. In the following remarks, 
and in those on the causes of croup, we refer the reader also to the table 
in the article on diphtheria, showing the comparative monthly and annual 
mortalities from these two diseases. 

From a glance at the accompanying table, it will be seen that since the 
prevalence of diphtheria, the mortality from croup has not increased dis- 
proportionately to the increase in general mortality. ^loreover, no change 
whatever has occurred in the type of this disease during the past ten years, 
for the experience of one of us for a number of years before the terra diph- 
theria came into use and appeared in the mortality returns of this city, 
enables us to attest the fact that pseudo-membranous laryngitis, both of 
the primary and of the more grave diphtheritic form, occurred then pre- 
cisely as it does now. 

Predisposing Causes — Age. — The disease is far most frequent between 
the close of the fii-st and fifth years. Thus of 2136 fatal cases reported in 
this city during the seven years from 1862-68, 301 were under 1 year of 
age; 571 between 1 and 2 years; 951 between 2 and" 5 years; or 1522 be- 
tween 1 and 5 years; and 236 between 5 and 10 years; leaving but 77 
cases as occurring after the latter period of life. 

Of the 35 cases that we have seen, 28 occurred between 2 and 7 years 
of age, while of the remaining 7, 1 occurred at the age of 18 months, 1 
at that of 19 months, 1 at 7^ years, 2 at 11 years, and 1 each at 11^ and 
12i years. 

Sex cannot be said to exercise any decided influence upon the frequency 
of the disease. Thus of the above 2136 cases, 1115 occurred in males, 1021 
in feraala-s. 

CoNSTiTiTioN. — A feeble and delicate constitution is thought by some 
to be a powerful predisposing cause, but this is at least very doubtful. 

Of the 35 cases referred to, of which we have preserved notes, 26 oc- 
curred in healthy vigorous children, while the remaining 9 occurred in 
children who, though neither very weak nor very sickly, presented a rather 
delicate appearance. 

Season exerts a very jwwerful influence upon the development of croup. 
Thus the mortality from it attains its maximum during the months of 
November, December, and January, during which quarter about four 
times as many deaths occur from croup as during the months of June, 
July, and August. It is, however, comparatively frequent from October 
to March inclusive. 

The relation between the mortality from croup and the temperature 
appears to be a definite and quite constant one, since, as will be seen by 
referrinjr to the table in the article on diphtheria, with the single excep- 
tion of February, the mean monthly teniperature and the mean monthly 
mortality from croup rise and fall together throughout the entire year. 

The ez4;iting causes are but little understood. The only ones which 
seem to have been ascertained with any certainty, are the application of 
irritating agents to the laryngeal mucous membrane, and exposure to cold, 
and even these are questioned by the most accurate observers. In none 
of the cases that we have seen could the exciting cause be even suspected. 



8S PSEUDO-MEMBRANOUS LARYNGITIS. 

It seems probable, therefore, that the existence of at least some predispos- 
ing constitutional condition may be assumed. 

Second Attacks of membranous croup, though rare, are mentioned 
as occurring by several authors; and, in our remarks on tracheotomy, 
we quote from Millard an allusion to five cases, in each of which the 
operation was twice successfully performed for successive attacks of this 
disease. 

We have ourselves met with two instances in which second attacks oc- 
curred. One was a girl, who had her first attack at the age of llj years, 
and her second at the age of 12^, and recovered from both without the 
operation. The second patient was a boy, who had his first attack, a very 
severe one, but from which he recovered without tracheotomy, at the age 
of 5 J years ; and his second attack, which is fully detailed at the end of 
the article on tracheotomy (Case 1), at the age of 7J years. 

Anatomical Lesions. — The false membrane may cover the whole 
mucous membrane of the larynx, and extend into the pharynx, trachea, 
and bronchia ; or it may be confined to the larynx, either forming a com- 
plete lining to the cavity of that organ, or consisting merely of patches 
of various sizes, with intervals of mucous membrane destitute of ex- 
udation. 

It is, in the first place, important, to ascertain the proportion of cases 
in which the deposit extends into the bronchia, and those in which it re- 
mains limited to the larynx, or larynx and trachea, as the determination 
of this point has some bearing upon the question of the propriety of the 
operation of tracheotomy. It appears from a table given by M. Guersent 
(Did. de Medecine, t. ix, p. 346), containing the results of cases collected 
by M. Hussenot from various sources, and of autopsies made by M. Bre- 
tonneau, numbering in all 171, that in 78 the membrane did not extend 
beyond the trachea, and that in 42 it invaded the bronchia, and in 30 the 
condition of the bronchia was not mentioned ; and in 21 there were no 
false membranes; so that of 120 cases, in which the extent of the false 
membrane was accurately noted, it was confined to the larynx and trachea 
in 78, and extended into the bronchia only in 42 ; or in about one-third 
of the cases. This proportion is the same that Millard gives {De la 
Tracheotomie dans le cas de Croup, These de Paris, 1858), in his masterly 
memoir upon croup, after an analysis of a large series of cases. Our own 
experience, based upon 15 cases in which we ascertained with exactitude 
(by autopsy or by tracheotomy) the extent of the membrane, would indi- 
cate that it passed into the bronchia in a larger proportion of cases ; since 
in 7 of these 15 cases the exudation extended beyond the trachea. It is 
to be borne in mind, however, that the cases upon which these calculations 
are based have very frequently resulted fatally, and presented extensive 
formation of pseudo-membrane in the bronchia ; and it is probable that it 
really exists there in other instances, but to a much less extent, so that 
recovery takes place, and renders it impossible to determine accurately 
the extent of the exudation. 

The proportion of cases in which the pharynx is'implicated is also im- 
portant, since it affects the diagnosis of the disease, and indeed bears upon 



ANATOMICAL LESIONS. 89 

the question of the identity or non-identity of pseudo-membranous laryn- 
gitis and diphtheritic croup. 

In considering the statements of authoi-s upon this subject it is evident 
that much of the diversity in their opinions depends upon the fact, that 
they are not in reality all referring exclusively to this particular affec- 
tion. Thus the assertion of M. Guersent (Diet, de Mai., t. ix, p. 339), 
that in nineteen-twentieths of the cases the exudation begins in the phar- 
ynx, is evidently to be explained on the supposition that this distin- 
guished practitioner had been observing a series of cases of diphtheria in 
which the exudation had extended into the larynx. MM, Rilliet and 
Barthez, on the other hand, state that a majority of the cases observed 
by themselves, and of those of M. Hache also, commenced in the larynx. 
Dr. We^t also report-s 11 cases of idiopathic croup, in only two of which 
was there any formation of false membrane upon the velum and tonsils. 

In 31 cai^es observed by ourselves, in which the condition of the throat 
was recorded, the croup followed membranous angina in 21 cases ; in 5 
the disease began in the larynx, but was attended later with small deposits 
upon the tonsils ; and in 5 only was there no deposit on the throat at any 
time. 

The fauces and pharynx do not present any constant alterations in cases 
of croup. Frequently, however, the mucous membrane is red and swollen, 
and there may be patches of membranous exudation upon the tonsils, 
velum, half-arches, or on the pharynx. These patches are usually thin, 
whitish, and may not persist more than 24 to 48 hours, disappearing and 
being succeeded by similar formations in some other part of the throat. 

We believe indeed that such patches of exudation will be found in a 
large proportion of cases during the first two or three days of the attack; 
and that they are not more frequently observed, chiefly because the symp- 
toms are usually so slight during this stage, that either no medical attend- 
ant is summoned, or his attention is not attracted to the throat. 

The most important and characteristic morbid appearances are, however, 
to be found below the glotti.s, and consist in the presence of pseudo-mem- 
braooufl exudation, and of certain alterations in the respiratory mucous 
membrane. 

The false membrane may be limited to the larynx, or to the larynx and 
trachea ; or it may extend over these parts and into the branches of the 
bronchi, even to the third and fourth division. In the larynx, trachea, 
and even the primitive bronchi, it may appear merely as patches of various 
sizes, with intervening .«paces of vascular mucous membrane; but in the 
gmaller air-passages it usually takes the form of complete tubes lining the 
broDchus. Jo some cases, such tubular casts may be formed continuously 
from the larynx down to the minute bronchioles, completely lining the 
air-passages. It is undoubted, that in the more sthenic idiopathic form of 
membranous laryngitis, the membrane is more apt to extend deeply into 
the ramificatioas of the bronchi, than when it occurs as a complication of 
diphtheria. 

The false membrane is commonly of a yellowish-white color, and from 
a fifth of a line to a line in thickne,*s. Its consistence is generally con- 



90 PSEUDO-MEMBRANOUS LARYNGITIS. 

siderable, and it is usually somewhat elastic ; indeed the more white and 
fibrous varieties possess a degree of firnmess and toughness that renders it 
difficult to tear the membrane, or teaze it out with needles. It is an al- 
most invariable rule, that the membrane lining the upper part of the air- 
passages is more white and firm than that found in the smaller bronchi ; 
so that it frequently happens, that, on drawing out the firm white tubular 
membrane lining the larynx, trachea, and primary bronchi, it is seen to 
terminate in branches which grow progressively softer, more yellow and 
purulent, as they become smaller and smaller. 

The free surface of the pseudo-membrane is usually covered with puri- 
form mucus, while the attached surface is adherent with various degrees 
of force to the mucous membrane beneath. The strength and closeness of 
these adhesions are often proportionate to the firmness and toughness of 
the false membrane itself. In the larynx and trachea it is often necessary 
to employ a good deal of force to separate the exudation from the mucous 
membrane, and innumerable little fibres are seen passing from one to the 
other, as though they were processes of exudation dipping into the minute 
orifices of the mucous follicles. On the other hand, the adhesion between 
the exudation and mucous membrane is rarely close in the smaller bron- 
chi, or in cases where the pseudo-membrane in the larynx and trachea is 
less firm and consistent. 

These false membranes consist, according to Hasse, mainly of fibrin 
blended with mucus in various proportions. {Path Anat, Syden. Soc. ed., 
p. 278.) On microscopic examination, they present a more or less close 
fibrous basis, consisting of interwoven fine fibrils, with imbedded cells in 
varying number ; these cells presenting the ordinary appearances of exu- 
dation-corpuscles, being round, granular, and containing from one to three 
small nuclei. The action of various chemical reagents upon them will be 
found detailed in the article on diphtheria. 

The mucous membrane beneath the exudation presents various shades 
of redness, or it is purplish, or even ecchymosed and blackish. It is also 
swollen, and may be slightly softened or friable, and has a dull excoriated 
appearance, though actual ulceration very rarely exists. West mentions 
the occurrence of small aphthous ulcers about the edges of the rimi glotti- 
dis and the arytenoid cartilages, as a frequent lesion in idiopathic croup; 
but the same lesion has been observed in the diphtheritic form of the dis- 
ease. 

There is also vascularity, though usually to a less marked degree, of the 
bronchial mucous membrane at the points where no exudation exists. 

The lungs present some abnormal condition in the great majority of 
cases. Bronchitis and pneumonia are frequent complications of the dis- 
ease ; and in addition there is often collapse of larger or smaller portions 
of lung-tissue from occlusion of some bronchus by the pseudo-membrane. 
In other instances, or frequently in conjunction with collapse of portions 
of the lungs,' the violent respiratory efforts induce either vesicular or even 
interstitial emphysema, especially of the anterior borders of the lungs. 

The morbid appearances found in cases where the croup has followed 



SYMPTOMS. 91 

diphtheritic angina, will be fully described under the head of this latter 
disease. 

In the secondary croup of measles, the appearances are very similar 
to those observed in primary case^, while in that of scarlet fever the ex- 
udation differs in being less consistent and less uniformly spread over the 
diseased part. In the last-named malady, the membrane is thinner and 
less adherent, and, in some cases, purif«)rm, soft, and of a grayish color. 
It is usually poor in fibrin, and prone to decomposition. The mucous 
membrane is generally discolored and softened. 

Symptoms. — In the majority of cases, the development of the symptoms 
characteristic of croup, is preceded for a few days by the ordinary symp- 
toms of catarrh and slight sore throat. The child is feverish and drowsy ; 
there is cough, which may possess a slight croupy character at some period 
of the twenty-four hours, but more frequently seems like an ordinary 
catarrhal cough ; coryza is very rarely present, but there is slight soreness 
behind the angles of the jaws, and the fiiuces are seen to be reddened, and 
probably small, thin patches of pseudo-membrane may be visible on the 
tonsils or fauces. This early stage lasts a variable time, usually from one 
to three or four days, and is more or less gradually succeeded by the 
symptoms indicative of laryngeal obstruction. 

When, on the other hand, the disease begins in the larynx, the invasion 
is marked by hoarseness of the voice, and hoarse, croupal cough, which 
often continue for one, two, or three days, until the disease has made con- 
siderable progress, before the parents deem it necessary to send for a 
physician. In a case that came under the observation of one of ourselves, 
the child was playing about the room at a time when he had hoarse, whis- 
pering voice, and cough, and stridulous respiration. In another we were 
not called until the evening of the third day, though the child had had 
stridulous cough and respiration for two nights ; but, as he always seemed 
better in the morning, it was not thought necessary to send for a j)hysician 
until after he had become violently ill. In a third case there was hoarse- 
ness of the voice and slight croupal cough during the afternoon of one day 
and the ensuing night, and the next morning fully devehjped croup, with 
fibrinous patches on each tonsil. These symptoms are not generally 
accompanied by fever at first. The appetite is usually unimpaired, the 
thirst scarcely augmented, and the child, though somewhat dull and 
languid, is disposed to be amused at times. In other and severer cases, on 
the contrary, the disease becomes aggravated much more rapidly, and may 
soon lead to a fatal termination. 

The change of the voice is the first symptom observed in the cases which 
begin in the larynx. It has always been described to us as hoarse, like 
that which is heard in an ordinary cold. As the disease progresses, the 
voice becomes more and more hoarse and difficult, until at length it is 
reduced to a mere whisper. The degree of the hoarseness varies, however, 
to a ver>' great degree in the same case, the diversities depending probably 
upon the amount of the spasm of the larynx at the moment, and upon the 
state of the exudation. We have several times observed the voice to be- 
come much stronger and clearer after the operation of an emetic, in con- 



92 PSEUDO-MEMBRANOUS LARYNGITIS. 

sequence, no doubt, of its relaxing effect upon the glottis. The cough is 
peculiar. At first slightly hoarse, it becomes, as the case goes on, very 
hoarse and hollow, and then short and smothered. It is variable in fre- 
quency, and is apt to occur in paroxysms, which are often very troublesome 
from their frequent recurrence. Towards the termination of the disease 
in fatal cases, or whenever the case is very severe, it is altogether different 
in character from what it was at the beginning, becoming short, instanta- 
neous, and smothered, so that it might very well be called whispering. As 
the disease progresses, it is accompanied by stridulous respiration, in which 
a hoarse, rough, hissing, or crowing sound is produced by the rush of the 
air through the constricted larynx. This sound is usually heard at first 
only during forced inspirations, and is therefore noticed first during the 
long inspiration which precedes coughing. Next it is heard during the 
violent respiratory movements which accompany the act of crying ; and 
as the larynx becomes more and more clogged with the exudation, it 
occurs during both inspiration and expiration, in every act of respiration, 
and is so loud as to be heard over the whole room, or even in adjoining 
rooms. 

The respiration is natural in the early part of the attack, but as the 
voice and cough assume their characteristic features, and the stridulous 
sound is established, it becomes more frequent, rising to 28, 32, 40, and 48 
in the minute. At first easy and natural, it becomes, during the height of 
the symptoms, and especially in fatal cases, the most frightful dyspnoea we 
have seen in any disease. Every movement of inspiration requires the 
whole force of the inspiratory muscles to lift the walls of the chest, and 
enable the air to find its way through the narrow and obstructed glottis ; 
each expiration, instead of being short and easy, as in health, and in 
nearly all other diseased conditions, requires a slow and laborious contrac- 
tion of the expiratory muscles to expel from the lungs the air which they 
contain, and which hisses through the larynx with a sound nearly as loud 
as that produced during inspiration. The dyspnoea just described is for 
the most part constant, but exhibits paroxysmal aggravations from time to 
time. 

When a paroxysm of dyspnoea occurs, the expression of the child is that 
of the most terrible anxiety, or of the wildest terror. In some instances, 
the face becomes deeply red, then blue, livid, and finally pale and white, 
and for a moment life may seem extinct. In other cases, in which the dysp- 
noea is constant, the face is of a dusky red color, tfie expression anxious 
and haggard, and the child either lies on its side with the head thrown 
far backwards in a state of somnolence, or constantly changes its position 
from restlessness without noticing anything around it. 

Jacobi (Amer. Jour, of Obstet, May, 1868, pp. 13-65) lays particular 
stress upon the fact that in membranous croup the dyspnoea exists both in 
inspiration and expiration, whereas in spasmodic catarrhal croup it is 
chiefly present in inspiration, and is due, he thinks, to paralysis of the 
crico-arytenoid muscles from oedema and infiltration, so that the vocal 
cords are brought into contact during inspiration. 

There is one further peculiarity about the dyspnoea in membranous croup 



AUSCULTATION. 03 

to which we would direct especial notice, since we regard it as of the 
utmost importance. This consists in the occurrence, in certain cases, of a 
deep sulcus around the base of the chest, and of recession of the lower 
part of the sternum and the epigastrium during the act of inspiration. 

These phenomena are, perhaps, partly due to the violent action of the 
diaphragm, but undoubtedly their chief cause is the atmospheric pressure, 
which acts here, as it has been clearly shown by Jenner to act also in 
rickets to produce the deformities of the thorax characteristic of that dis- 
ease. The normal relation which exists between the firmness and resist- 
ance of the thoracic walls, the power and rapidity of contraction of the 
diaphragm, the elasticity of the lungs, and the size of the orifice of the 
larynx, is here disturbed by the greater or less degree of occlusion of the 
larynx by membranous exudation. The calibre of the larynx being thus 
diminished, so that air enters the lungs but slowly, and the diaphragm 
contracting violently, there will necessarily be recession of the softer parts 
of the chest-walls at each inspiration. 

The persistence of these phenomena during inspiration for even a short 
time is, we believe, in the highest degree characteristic of the presence of 
false membranes in the larynx ; and when, despite the use of emetics, this 
form of respiration continues, it constitutes one of the strongest indica- 
tions for the performance of tracheotomy. 

There is no expectoration early in the disease, or it consists of yellowish 
viscous mucus. At a later period there is usually expectoration of false 
membrane, sometimes in the form of a complete tube, or, much more fre- 
quently, of small, irregular fragments, mixed with mucus, or with the 
matters ejected from the stomach by vomiting. To detect the membrane, 
the substances expectorated or vomited ought to be placed in water, when 
the former detaches itself from the mucus and other matters, and is easily 
recognized. It is not voided in all cases in which it is known to be present 
in the larynx. 

Thus of the 3-5 cases observed by ourselves, it was expelled by vomiting 
or coughing in 12; in 21 none was rejected, though its presence in each 
case was proved by the character of the symptoms and by its existence in 
the fauce?, by autopsy, or by the operation of tracheotomy ; in one there 
was expectoration of mas.>ie8 of viscid, yellowish fibrin, though none of 
membrane; and in one there was no positive evidence of its existence. M. 
V'alleix (Guide du Mid. Prat., t. i, p. 330) states that of 51 cases, in which 
the symptoms were very carefully observed, no traces of the exudation 
could be discoverefl either in the expectoration or in the matters rejected 
by vomiting in 26, though itij existence was proved by post-mortem exami- 
nation. 

AusKTLTATioN. — In the severe ca.«es of true croup that have come 
under our notice, auscultation has been of little or no aid. In fact, the 
chest-sounds have been, in most cases, so completely masked by the loud 
shrillne^ of the laryngeal stridor, that we have been unable to judge with 
any satisfaction to ourselves of the condition of the lungs. It has been 
impossible to determine whether the inability to detect natural respiratory 
murmur def)ended on thf .«iniall vojiinu; of air that found its way through 



94 PSEUDO-MEM*BRANOUS LARYNGITIS. 

the obstructed larynx, or on the fact that all sound was masked by the 
stridor. This is particularly unfortunate, since, were it not for this cir- 
cumstance, we might be able to judge by auscultation of the extent to 
which the bronchia have been invaded by the false membrane, — a matter 
very important to determine when the question of tracheotomy comes to 
be mooted in any case. 

In cases in which the laryngeal obstruction is not very great, and the 
stridulous sound consequently less loud, we may auscult the chest to some 
profit. The vesicular murmur is then either natural, or altered according 
to the state of the lung. 

But though such has been our own experience in regard to auscultation 
in croup, MM. Barth and Koger {Trait. Prat, d' Auscultation , 2eme ed., pp. 
255 and 261) describe, as a sign of croup with floating false membrane, a 
kind of vibrating murmur, or tremblotement, as though a movable mem- 
branous veil were agitated by the respired air, and which can be heard 
when the stethoscope is applied over the larynx or trachea. If this sound 
be heard only in the larynx, and not in the trachea and bronchia, it indi- 
cates the plastic exudation to be of small extent, and likely to be rejected 
by expectoration, and the prognosis is favorable. In the other case, on 
the contrary, it shows the disease to be of considerable extent, and the 
prognosis becomes much more serious. 

This question will be found referred to more fully in our remarks on the 
indications for the operation of tracheotomy. 

There is a sWght febrile movement at the onset, or a day or two after the 
appearance of the earliest symptoms. When the disease is fully estab- 
lished, the fever becomes violent. The pulse rises to 130, 140, 160, or even 
higher ; it is generally regular and strong at first, but as the case pro- 
gresses, becomes small, feeble, and very rapid. In one of the paroxysms 
that we witnessed, it became so rapid that it could not be counted, and at 
last ceased to beat at either wrist for a few instants. The heat and dry- 
ness of the skin are very moderate at first, but increase as the disease 
reaches its maximum, to diminish afterwards gradually, and in fatal cases, 
to be replaced by coldness, with copious clammy perspirations. The 
strength is not diminished at first, but as the disease progresses, becomes 
more or less so in proportion to the violence and duration of the case. 
The digestive organs are but little disturbed by the influence of the disease, 
with the exception of diminution or loss of appetite, and moderate thirst, 
during the violent period. Spontaneous vomiting or diarrhoea are rare, 
though both sometimes occur. The tongue is moist, and generally cov- 
ered with yellowish-white fur. Pain in front of the larynx has been 
noticed by several authors. We have ourselves observed it in but one 
case. 

Tumefaction of the submaxillary glands, which is a frequent symptom 
of pseudo-membranous angina, ought always to be sought for, and when 
present lends additional support to the diagnosis. 

The mode of recovery in favorable cases is different in different instances. 
In some it is sudden, taking place rapidly and steadily after the expecto- 
ration of a tubular-shaped membrane. The rejection of the deposit in 



MODE OF RECOVERY — DURAtlON — DIAGNOSIS. 95 

this form is, however, a rare event, and is not always followed by recovery. 
We have seen in this city three distinct tubnles of false membrane, which 
were thrown from the larynx of the same chihl at intervals of two days 
each. The first was the largest, and came evidently from the whole length 
of the larynx and trachea ; the second was somewhat shorter, and the 
third not more than half so long as the first. The child was greatly re- 
lieved for some hours on each occasion of the rejection of a tubule, but 
then became more oppressed as the exudation again collected. It sank 
from exhaustion after the third came away. 

As a general rule, the recovery is slow and gradual. After free vomit- 
ing, after the expectoration of fragments of false membrane mixed with 
mucus, or, as happened to ourselves in two cases, after the expectoration 
of masses of tough yellowish fibrin, or, lastly, after the rejection of mucoid 
and frothy sputa only, the symptoms gradually ameliorate ; the stridulous 
respiration slowly subsides, and at last disappears; the cough, which was 
short, hoarse, and smothered, becomes louder, stronger, less hoarse, and 
what is still more favorable, loose ; the aphonia moderates, but very slowly; 
the fever disappears; appetite and gayety' return ; and, after a variable 
length of time, the child enters into full convalescence. The hoai*seness 
of voice very generally continues for several days after all the other symp- 
toms have lost their dangerous character, and sometimes lasts for weeks. 
In one case the voice was still weak and hoarse on the tenth day, and in 
another during the seventh week. {See a paper on Croup, by J. F. Meigs, 
M.D., Am. Med. Jour. Med. ScL, April, 1847.) 

Duration. — Death has been known to occur on the first, second, and 
third days, but such cases are rare. The duration of the disease may be 
stated at from three to thirteen days, as its most common term. Tlie cases 
seen by ourselves lasted from five to fourteen days. 

Diagnosis. — There can be no difliculty in recognizing the presence of 
pseudo-membranous laryngitis, when the development of the symptoms of 
lar}-ngeal obstruction has been preceded for several days by angina, with 
or without membranous exudation, and hoarseness of voice and cough. 
For the relation which exists between such cases and diphtheritic croup, 
the reader is referred to the remarks at the begiuniug of this article on 
the nature of croup, and to the remarks made under the head of diagnosis 
in the article on diphtheria. 

When, however, the disease begins in the larynx, and especially when 
there is no exudation whatever in the fauces, the diagnosis becomes more 
embarrassing, .«ince under these circumstances there are two other larvn- 
geal affections with which true croup maybe confounded, to wit: false 
croup or spasmodic catarrhal laryngiti.^, and laryngismus stridulus. The 
mode of distinguishing between these different disorders has been carefully 
described in the remarks on diagnosis, under the head of the former dis- 
ease. We wish in this place merely to call the attention of the reader, 
and particularly of the young practitioner, to the extreme importance of 
the differential diagnosis between the disease now under consideration, and 
false or spasmodic croup, since the former is one of the most dangerous 
and frightful disorders to which children are subject, demanding vigorous 



96 PSEUDO-MEMBRANOUS LARYNGITIS. 

and active treatment from the start, at which period only is medical treat- 
ment likely to be successful ; whilst the latter, though of a much more 
threatening aspect at the beginning, is in fact a mild and safe disease in 
comparison, and one rarely requiring other than very simple treatment. 

In this connection we would urge again the extreme importance of a 
careful examination of the throat in every case where there are even the 
most trifling croupy symptoms present, since if menibranous exudation be 
present either on the pharynx or tonsils, there is great danger that the 
laryngeal symptoms are due to an extension of the false membrane. 

Prognosis. — Pseudo-membranous laryngitis is a very fatal disease. In 
its sporadic form it is decidedly less dangerous than when it occurs in the 
course of epidemic diphtheria, owing to an extension of the exudation from 
the fauces into the larynx ; but it still ought, at all times and in all shapes, 
to arouse the utmost caution of the practitioner. 

MM. Rilliet and Barthez state that its common termination is in death. 
M. Valleix says that, " to speak in general terms, it is fatal when not 
treated energetically." M. Guersent {loe. cit, p. 365), after a careful con- 
sideration of the statements of various authors, says: "In fact, true croup 
is one of the most dangerous of all diseases ; it is generally fatal." He 
adds that he has seen at least 100 cases of spasmodic croup without a 
single death, while of 10 children attacked with true croup, it is scarcely 
possible to save two. 

We have ourselves seen upwards of 200 cases of spasmodic or false 
croup, all of which without exception recovered, while of the 35 cases of 
true croup, of which we have preserved careful notes, 16 died. 

The danger is great in proportion as the child is younger and more 
feeble, and in proportion to the rapidity of the case and the degree of the 
dyspnoea. The most unfavorable symptoms are : loud stridulous sound, 
heard both in the inspiration and expiration ; laborious, and prolonged 
expiration ; recession of the base of the thorax during inspiration ; whis- 
pering voice or complete aphonia ; congestion of the face and neck ; som- 
nolence ; weak, rapid, and irregular pulse ; cold extremities ; and cold, 
clammy perspirations. The favorable symptoms are: expectoration of 
false membranes ; diminution of the stridulous respiration ; the change 
from whispering to hoarseness or to clearness of the voice ; looseness of 
the cough ; moderation of the fever ; improvement of the temper and 
moral state ; and amelioration of the general condition. 

The case should not, however, be abandoned as hopeless until life is ac- 
tually extinct. An instance has been elsewhere put on record by one of 
us (see paper by Dr. J. F. Meigs, loc. cit.) of the recovery of a child after 
momentary suspension of animation from asphyxia on two occasions, 
though these attacks were followed by a dreadful illness of two days. , 

Treatment. — We are desirous, at the beginning of our remarks upon 
the treatment of this disease, to express the opinion, that none is likely to 
succeed, unless it be applied early in the case, and by this we mean, in 
the course of the first, or at the latest, second day. And not only should 
it be commenced early, but the most active remedies ought to be applied 
at this period, in their full force. The very moment there is good reason 



TREATMENT — BLOODLETTING. 97 

to suppose that a case will prove to be oue of membraDOUs croup, the most 
energetic means ought to be brought to bear upon it, and if this be done 
from the first, or even second day, we cannot but hope that a considerably- 
larger proportion of recoveries may take place than has heretofore been 
thought possible. 

In the study of the treatment, it will be ne^cessary to rely chiefly upon 
the works that have been published since the distinction between the two 
forms of croup has been correctly drawn, for it is impossible to place 
much de}>endence on the assertions of previous writers, inasmuch as their 
opinions in regard to the eftect;s of treatment must have been formed from 
indiscriminate experience in two very opposite maladies. It is only nec- 
essary to recollect the enormous difference in the mortality of the two 
affections, as shown by our own experience and the statistics quoted from 
Guersent, to be convinced that the success of any plan of treatment in the 
one, is no fair argument for its probable success in the other. The most 
important objects to be held in view in the treatment, are the following: 
to prevent, if this be at all possible, the formation of false membrane; after 
its production, to cause its dissolution, or render it less adherent; to pro- 
voke its expectoration; to prevent its reproduction after it is once expelled; 
to subdue the inflammatory diathesis which exists ; to allay the painful 
symptoms; and in every way to support the system. 

Bloodletting. — Some authors still award to bloodletting a high place in 
importance amongst the medical means in our possession, and it was for- 
merly regarded by many in this country as an indispensable agent in the 
cure. Moreover, there are not a few who believe that, when promptly and 
boldly resorted to, it will seldom fail in arresting the disease. 

The more careful and extended study which this question has received 
during the past few years, however, has led many observers to doubt the 
efficacy of venesection in arresting the course of this inflammation, or pre- 
venting the formation of membranous exudation. 

In those cases where croup supervenes in the course of epidemic diph- 
theria, there can be no doubt that bloodletting is entirely contraindicated; 
and the same remark may be made of those sporadic cases of pseudo-mem- 
branous laryngitis, where the onset of the disease is slow, and its course 
gradual, and unattended by high febrile reaction. Indeed, the more wide 
experience we have ourselves had in the treatment of this disease during 
late years, has convinced us that bloodletting is, to say the least, unneces- 
san*', excepting perhaps in cases where the disease occurs suddenly in 
vigorous children, and is attended at an early period of the attack by 
violent febrile action and especially marked suff(jcative symptoms. Under 
such circumstances, and such only, it may be advisable to resort to a 
moderate general venesection, principally for the mechanical relief thus 
afforded to the acute and intense venous stasis caused by the obstructed 
respiration. 

For all the other indir-ations, however, for which bleeding was formerly 
recommended in croup, namely, for the reduction of the fever and inflam- 
mation, and for the arrest of the exudative process, we prefer resorting to 
the other remedies hereafter mentioned. 

7 



98 PSEUDO-MEMBRANOUS LARYNGITIS. 

Emetics. — Emetics are recommended by all writers, and are generally 
acknowledged to be amongst the most, if not the most, efficient of all the 
means employed. M. Valleix (op. cit, i. i, p. 358) has demonstrated their 
importance more fully than any other writer. He states that of fifty-three 
cases of the disease, tartar emetic and ipecacuanha were chiefly relied on 
in thirty-one, of which fifteen were cured ; whilst of the twenty-two others, 
in which they were parsimoniously given, but a single one recovered. He 
gives other facts in regard to these cases which are highly interesting and 
important. Thus, of the thirty-one cases treated with powerful emetics, 
false membrane was rejected during the efforts of vomiting in twenty-six ; 
and of these, fifteen, or nearly three-fifths, recovered. In the five others 
of the thirty-one, on the contrary, no membrane was expelled, and they 
all terminated fatally. Again, of the twenty-two cases in which emetics 
formed but a secondary part of the treatment, two rejected false mem- 
brane, and of these one recovered ; while of the twenty others in which no 
false membrane was expelled, not one escaped. 

Our own experience in regard to emetics has been as follows : They 
were administered frequently and in full doses in thirteen of the twenty- 
one cases which began with angina, of which we have preserved notes ; in 
six they w^ere employed to a moderate extent, and in two not at all. Of 
the thirteen cases in which they were freely administered, eleven recovered ; 
but, as in one of these life was saved only by tracheotomy, the success can- 
not be attributed to the emetics. Of the eight cases in which the emetic 
plan was not pushed, all but one ended fatally. False membuane was re- 
jected in eight out of the thirteen cases above referred to. In one of the 
eight cases the quantity rejected was very small, and this was the case in 
which the child was ultimately saved only by operation. 

Of thirteen cases in which the disease began in the larynx, emetics were 
energetically used, and frequently employed, in eight. Of the eight, five 
recovered. In four of the eight cases, fragments of false membrane were 
rejected, and in a fifth, a mass of viscid, yellowish fibrin (this case was 
marked as one of unquestionable membranous croup by patches of false 
membrane on the tonsils). Of these five, four recovered. In three of the 
eight, no false membrane was rejected, and of these two died. In five of 
the thirteen cases they were not freely used, being employed in two only 
as a secondary means ; in one other only at the very termination of the 
attack, as we were not called to the case until the tenth day, the patient 
having been under homoeopathic treatment before ; and in the remaining 
two cases they were not employed at all. Tracheotomy was performed in 
four of these five cases, but in only one was a successful result obtained. 

It is indeed true that there were peculiarities about the age and the 
type of the disease in the above groups of cases which may modify to 
some extent the conclusions which seem inevitable ; but the statements 
and facts above given are quite sufficient to show that emetics exert a 
most powerful and beneficial influence on the disease, and that they ought, 
therefore, to form a principal and essential part of the treatment. 

The emetics generally employed in Europe and this country are tartar 
emetic and ipecacuanha, which are given in the usual doses to produce 



i 



TREATMENT — EMETICS. 99 

full vomitiug. We would, however, strongly discouuteuanee the employ- 
ment of tartar emetic as an emetic, under any circumstances, in children; 
and, at least in the disease under consideration, we do not like ipecacuanha 
as an emetic so well as one which, so far as we know, was fii-st recom- 
mended by the late Dr. Charles D. Meigs. We refer to the Alumcn of the 
Pharmaco|xiMa. 

In an article published by him in the Medical Examiner (vol. i, p. 414, 
1838), he says he has been " accustomed to make use of an emetic, which, 
so far as I can learn, is very little employed, but which, from the certainty 
and the speediness of its operation, ought to be more generally admitted 
into the list of available medicines for this particular case at least. I 
have been familiar with its effects for more than twenty years, and my 
con6dence in them increases rather than diminishes by time." He adds, 
" I think that I have never given more than two doses without causing 
very full vomiting ; but I have often given large quantities of antimonial 
wine and ipecacuanha, without succeeding in exciting the efforts of the 
stomach." 

The alum is given in powder, in the dose of a teaspoouful, mixed in 
honey or syrup, or in syrup of ipecacuanha, to be repeated every ten or 
fifteen minutes until it operates. It is not generally necessary to give a 
second dose, as one operates in the majority of cases very soon after being 
taken. We have known it to fail to produce vomiting only in two in- 
stances, both of which were fatal cases. In one the disease had gone so 
far before we were called, that no remedy had any effect upon the stomach. 
In the other, it was administered several times with full success, but lost 
its effect at last, as had happened also in regard to antimony and ipecacu- 
anha. The reasons for which we prefer alum to antimony, or ipecacuanha 
alone, are the following: Antimony, when resorted to as frequently in the 
disease as we are of opinion that emetics ought to be, is too violent in its 
action ; it prostrates many children to a dangerous degree, and is, we fear, 
in some cases, itself one cause of death. It acts injuriously upon the 
gastro-intestinal mucous membrane when used in large quantities and for 
any considerable length of time. Again, it is very apt to lose its effect, 
and to fail to produce sickness. Ipecacuanha is a nuich safer remedy than 
tartar emetic, but its operation is often too mild, and it not unfrequently 
fails to produce any effect after it has been used several times. The ad- 
vantages of the alum are that it is certain and rapid in its action, and 
that it operates without producing exhaustion or prostration beyond that 
which always follows the mere act of vomiting. It does not tend like 
antimony, and in a less degree ipecacuanha, to produce adynamia of the 
nervous system ; an effect which, in some constitutions or states of the con- 
stitution, or when it has been exhibited frequently, is often attended with 
injurious or even dangerous consequences. We have given alum in the 
dose above mentioned every four or five hours, for two and three days, 
without observing any bad effects to result from it. The alum was given 
in all the cases that we have seen, in which eraetio were used, and was 
usually the only one employed when it was found to produce full vomit- 
ing. In one of the cases accompanied by violent angina, ipecacuanha 



100 PSEUDO-MEMBRANOUS LARYNGITIS. 

was substituted because of its smaller bulk. We have already said that 
it failed to produce vomiting only in two instances. It was the emetic 
employed in the nine cases in which fragments of false membrane were 
rejected, and in that in which the yellow viscid fibrin was expelled. Al- 
though it did not occasion the rejection of membrane in the other cases, it 
operated most speedily and efficiently. 

Sulphate of copper has been highly recommended by several writers for 
its emetic operation, and, by some of the German physicians, as exerting 
a specific influence upon the disease in addition to its emetic effect. As 
an emetic, it may be given to a child two or three years old, in the dose 
of from half a grain to a grain every fifteen minutes, until it operates. To 
obtain its specific action it is continued afterwards in doses of a quarter of 
a grain every two hours. 

We have also employed, with very good results, sulphate of zinc dis- 
solved in syrup of ipecacuanha, in the proportion of 2 or 4 grains to the 
fluid ounce. Of this, a teaspoonful may be given to a child two or three 
years old, and repeated every fifteen minutes until it operates. This com- 
bination appears, like that of alum and ipecacuanha, to possess the double 
advantage of mild action without the production of any subsequent de- 
pression. 

In the third edition of this work we referred to the use of the yellow 
sulphate of mercury (Hydrargyri Sulphas Flava) as an emetic in croup, 
as recommended by Dr. Hubbard, of Maine. Our own experience with 
this remedy has been limited, and not very decided. In the American 
Journal of Obstetrics, for May, 1870, Dr. Fordyce Barker, of New York, 
speaks in the highest terms of praise of its emetic effects in this disease. 
He always commences the treatment by a dose of from three to five grains, 
according to the age of the child, which may be repeated if it do not act, 
which he states very rarely occurs, in fifteen minutes. This he follows up 
with the use of veratrum viride, and states that the treatment has been' 
successful in every case of true croup in which he has employed it. Un- 
doubtedly this high testimony in its behalf justifies a further trial of tur- 
peth mineral in croup, though we confess to a suspicion that not a few of 
the cases in whose incipient stage he has administered this drug so success- 
fully would have proved to be instances of the severe catarrhal and not of 
the true membranous form. 

We conclude these protracted remarks upon emetics with the statement 
that from what we have read, and from personal experience, we are in- 
duced to regard them as the most important remedies we have to oppose 
to this fearful malady. The emetic, whatever it may be, ought to be given 
three or four times in the twenty-four hours, and in severe cases, once in 
every four or five hours. The exact periods and frequency of the admin- 
istration must be determined by the stage and urgency of the symptoms, 
and by the constitution and present strength of the patient. 

Mercury. — This powerful drug was first employed freely in the treat- 
ment of membranous croup in America, and has subsequently been exten- 
sively used by English and European physicians. Calomel is the prep- 
aration almost always preferred, and many authors still recommend the 



LOCAL TREATMENT. 101 

administration of this remedy, in larger or smaller doses, iu the earliest 
stage of the attack. 

During late years, our increased dislike of the administration of mer- 
cury to children in large and frequently repeated doses, and the constant 
observation that even its free use does not appear to arrest the course of 
true croup, or prevent the formation of membranous exudation, have led 
us to abandon entirely its employment in this disease. 

At the same time we believe there has been found, iu the free admin- 
istration of the alkalies, an agency far less injurious than mercury, and 
equally powerful, if not more so, iu promoting the separation and discharge 
of the exudation, and preventing its reproduction. 

The internal remedies, then, upon which, after emetics, we rely most 
surely, are various alkaline salts, the use of which iu large doses, has 
been of late years highly recommended, both at home and abroad. Those 
which we are most in the habit of employing are the chlorate and citrate 
of potash, which should be given in full and frequently repeated doses, as, 
for example, two or three grains every two hours to a child of four years 
old. We are also in the habit of combining with the chlorate of potash, 
tincture of the chloride of iron, in doses of three to five drops, at the same 
age. 

Anthpasmodics are undoubtedly useful in some cases, when there is 
much laryngeal spasm. 

Opium is, however, the best remedy that can be employed for this con- 
dition, since it constitutes an important element in the treatment, by allevi- 
ating pain and restlessness, at the same time that it relieves the laryngis- 
mus, and thus diminishes the asphyctic symptoms. AVe would consequently 
recommend the use of some of the preparations of opium, as the tinct. opii 
deodorata, in such doses and at such intervals as will maintain a gentle 
opiate impression. In this, as in many other diseases of children, it is 
better not to prescribe the opium in combination with the other remedies 
that may be administered, but to either give it separately, or better still, 
to add it to the dose of the other medicines at the time of administration, 
80 that the amount of the dose of opium and the frequency of its repeti- 
tion may be modified constantlv in accordance with the condition of the 
child. 

Revulsives often prove useful in allaying restlessness, and moderating 
the violence of the suffocative attacks. Sinapisms and mustard poultices, 
applied upon various parts of the cutaneous surface, and mustard foot- 
baths, are amongst the best. The warm bath is often highly beneficial in 
the same way. 

We do not think it desirable ever to employ blisters in this disease. 

Lkx'AL Treatment. — In those cases, and, as we have seen, they consti- 
tute the large majority of all cases of true croup, where the exudation 
appears in the fauces or on the tonsils before it involves the larynx, local 
applications to the throat are undoubtedly of importance. 

The objects of such applications are here, as in diphtheritic angina, to 
promote the separation of the false membrane, and to prevent its repro- 
duction. To fulfil thf first f)f thf'sc indifations, manv authorities rccom- 



102 PSEUDO-MEMBRANOUS LARYNGITIS. 

mend astringent and caustic applications, which cause the pseudo-mem- 
brane to contract and shrink, and thus tend to promote its separation ; 
while others direct the use of those agents which exert a solvent action 
upon the exudation. 

In the former class, the most advisable are, alum ; tannic acid ; solu- 
tions of nitrate of silver ; the astringent salts of iron, especially the tinc- 
ture of the chloride and the perchloride; dilute mineral acids and carbolic 
acid. 

Of these applications, those which we prefer are a solution of nitrate of 
silver, in the proportion of 5 to 20 grains to f ^j of distilled water ; and 
tincture of the chloride of iron, in the proportion of f3ss. to fjij, to the 
f 5j of water. 

The second group comprises chiefly solutions of various salines, as the 
carbonate of potash, bicarbonate of soda, chlorate of potash ; and lime- 
water. 

If any of the astringent or caustic solutions are employed, we would rec- 
ommend their application only to the patches of exudation in the fauces, 
since we regard it as highly doubtful whether they actually possess the 
power of preventing the formation of membranous exudation when ap- 
plied to the surrounding mucous membrane. Still more should we doubt 
the efiicacy or advantage of introducing such solutions, and especially the 
more powerful ones, into the larynx ; either by pressing a soft sponge sat- 
urated with the solution upon the chink of the glottis, or by passing the 
sponge directly into the cavity of the larynx, as recommended by Dr. 
Horace Green. {Observ. on the Path, of Croup, etc., New York, 1852.) 
The practicability of this proceeding is undoubted, and a certain number 
of cases are on record in which it seems to have been used with success ; 
but we have never resorted to the treatment ourselves. 

In cases occurring in older children, who can be induced to inhale the 
vapor from an atomizer, or to allow a hand-ball atomizer to be used, the 
various astringent and solvent solutions above mentioned can be applied 
most satisfactorily in this manner ; and, when this is practicable, we would 
prefer the use of lime-water or one of the alkaline solutions. 

We attach so much importance to this remedy, and have found it to be 
followed by so much relief and comfort that we are in the habit of direct- 
ing the inhalation of vapor of lime-water for five or ten minutes at least 
every two hours. 

In order to obtain the advantage which undoubtedly follows the inhala- 
tion merely of the watery vapor, we are in the habit of causing the child 
to inhale the vapor from slaking lime for a few minutes in every hour, by 
covering the patient's body with a thick cloth, and holding a vessel con- 
taining the slaking lime a short distance below his mouth under the cover- 
ing. It is doubtful, however, whether any appreciable amount of lime is 
carried up by the vapor so as to give the additional advantage of its sol- 
vent action upon the exudation. 

The reader is referred for more detailed discussion of this question of 
local applications in the treatment of croup, to the remarks upon treatment 
in the article on diphtheria. 



I 



HYGIENIC TREATMENT — TRACHEOTOMY. 103 

Hygienic Treatment. — The child ought to be warmly clothed, and 
confiued to bed. The temperature of the room should be kept equable, 
and about 70° F. ; the air should also be frequently changed, so as to pre- 
serve it constantly pure and fresh. 

Owing to the loss of appetite and the pain caused by deglutition, it is 
often very difficult to induce the little patients to take food, so that this 
important element in the management of the case requires the utmost tact 
and attention. During the early part of the attack, the food should con- 
sist of light animal broths, beef tea, and preparations of milk. Later in 
the case, when the violence of the febrile action subsides, or if any symp- 
toms of exhaustion and prostration appear, a small amount of wine and 
water, of wine whey, or of weak milk punch, should be given. 

Ice, given in small pieces to be held in the mouth, should be used very 
freely, a.s it relieves the parching thirst and at the same time appears to 
act favorably upon the inflamed mucous membrane. 

Summary of the Treatment. — The general plan of treating this dis- 
ease should, therefore, in our opinion, be somewhat as follows : The child 
should be confined strictly to bed. The food should be light, digestible, 
but nourishing, and, upon the earliest approach of exhaustion, a stimulus 
should be administered. In the early part of the attack, we should advise 
the use of revulsives, with mild counter-irritants ; topical applications to 
the fauces if there is any membranous exudation visible, and the internal 
administration of citrate of potash, with ipecac and small doses of opium, 
or of chlorate of potash with tr. ferri chloridi. So soon as the symptoms 
positively indicate the presence of false membrane in the larynx, we should 
resort to emetics, as directed in our remarks upon those remedies. During 
the whole treatment we should also recommend frequent inhalations of the 
vapor of lime-water or some other alkaline solution. And finally, after 
employing these means faithfully but without securing the discharge of the 
false membrane, while, on the other hand, the symptoms of laryngeal 
obstruction steadily progress, and the respiration grows more and more 
difficult, we must consider the propriety of resorting to the operation of 
tracheotomy, a proceeding which, as will be seen from the ensuing remarks, 
we approve of under the above circumstances. 

Tracheotomy. — The operation of tracheotomy would be apt to suggest 
itself to a medical man, on his witnessing the closing symptoms of croup, 
as the very means most likely to aflford to the patient relief from the dread- 
ful sufferings under which he labors, and as a possible rescue from impend- 
ing death. It has accordingly been often resorted to in different parts of 
the world, at various .stages of the di.sease, but with results that have led 
to ver}' different conclusions. 

In England, for example, the operation was almost universally con- 
demned and abandoned about ten years ago ; and in a former edition of 
this work, we presented the unfavorable opinions of the most eminent 
English authorities. 

It was a matter of very great surprise, at that time, that the results of 
the operation in the hands of Engli.sh surgeons should differ so widely 
from those obtained by the French physicians in similar cases. And, sm 



104 PSEUDO-MEMBRANOUS LARYNGITIS. 

there was no good ground for believing that sufficient difference existed 
between the croup of Paris and Loudon, to explain the difference of suc- 
cess in the two cities, it is probable that the great disparity resulted, in 
part, from the operation being performed in France at an earlier stage of 
the disease, and in part also from the more careful after-treatment which 
the patients received. 

Within the past few years, however, the operation has been more favor- 
ably regarded by English surgeons, and the statistics published show that 
the proportion of success now obtained does not fall far short of that 
claimed by French operators. 

Thus in a paper read before the Eoyal Med.-Chir. Soc, in 1857, by Dr. 
Fuller, it is stated that up to that time 22 cases of tracheotomy in croup 
had been recorded in England, and that life had been saved in 8 of these, 
or in 1 out of every 2f cases. 

In the statistical report of English Hospitals from 1854-59, it appears 
that the operation had been performed in 15 cases with 4 recoveries, or 1 
in every 3| cases. Still further, from the statistics published by indi- 
vidual operators in England, since 1858, though it is not to be presumed 
that we have met with all the cases recorded, it appears that tracheotomy 
has been resorted to in 63 cases, with successful results in 24, showing a 
success of 1 in 2f . 

When it is borne in mind also, that in each of these instances the opera- 
tion was postponed to the last suffocative stage, and that without exception 
the operators believe that the proportion of success would have been in- 
creased by its somewhat earlier performance, it becomes evident that 
tracheotomy has acquired a fair position in England among the legitimate 
operations of surgery. 

It is thus advocated by Fergusson in the last edition of his Practical 
Surgery; and Dr. West, in 1859, speaks of it in these terms: "In spite 
of the unfavorable issue of the few cases in which I have either directed 
or sanctioned the performance of tracheotomy in croup, I am so far from 
being opposed to the operation, that my chief anxiety is to make out the 
indications which may justify me in having more timely recourse to it in 
future." 

In Germany, also, the operation, if not generally practiced, is regarded 
as fully justifiable, and recommended and successfully performed by many 
of the most eminent authorities. 

The statistics of the results there obtained, borrowed from Fock ^ and 
Voss,^ show that of 50 cases operated on in the last stage, 24 terminated 
favorably, giving a success of 1 in 2yL^ or 48 per cent. Steiner has also 
recently published {Jahrh. /. Kinderheilk., No. 1, 1868) the results of the 
operation in 52 cases (33 boys and 19 girls), which show a recovery of 18, 
or 34.6 per cent, of those operated upon ; and in an article upon diphtheria 
and tracheotomy by Giiterbock {Arch. d. Heilhunde, 1867, No. 6) 100 cases, 
operated on in Berlin, are reported, with 33 cures. 

1 Keport on Tracheotomy. Brit, and For. Med.-Chir. Kev., July, 1860, from 
Deutsche Klinik, 1860. 
' New York Journal of Medicine, January, 1860. 



TRACHEOTOMY — STATISTICS. 105 

It is, however, in France that the operation first obtained, and has since 
firmly held, the position of a proper and legitimate method of treatment 
under certain circumstances of the disease. M. Bretonneaii, of Tours, was 
the first who practiced it with sufficient success in France to give it some 
vogue. Since that time, it has been recommended and performed by many 
dit!erent surgeons and physicians in that country, and particularly, as is 
well known, by M. Trousseau, who has been undoubtedly the most ardent 
and persevering, as well as the most experienced advocate of the operation. 
In one of his later publications upon this subject {Arch. Gen. de Med.y 
Mars, 1855, p. 259\ he thus boldly advocates it : " For ray part, I am quite 
determined not to allow myself to be discouraged, but to preach trache- 
otomy with the greater conviction in proportion as its success increases, 
and did this proportion remain what it was ten years since, I should still 
proclaim the necessity of the operation, nor cease to say that it becomes a 
duty, a duty as imperative as the ligature of the carotid artery after a 
wound of that vessel, though death follows the operation as often, certainly, 
as recovery." 

M. Guersent {Did. de Med., t. ix, p. 376) recommends the operation 
when the usual therapeutical methods have failed, "as the only means 
that offers a remaining chance." He adds (p. 377) that he is certain it 
does not add to the danger of the disease. MM. Rilliet and Barthez (Mai. 
des Etifants, 2^me ed., t. i, p. 337) say that " the utility of tracheotomy in 
the treatment of croup cannot at this day be denied ; numerous cases of 
children snatched from a certain and imminent death, reply victoriously to 
any doubts that may be raised as to the truth of this assertion." The 
authors of the Comp. de Med. Prat. (t. ii, p. 587) remark that of late years, 
" the successful operation.s have been numerous enough to dispel the unfor- 
tunate prejudices which tracheotomy has hitherto inspired." M. Yalleix 
{Guide du Med. Prat., t. i, p. 388) says that the number of recoveries are 
" now too numerous to allow any one to think of opposing the operation 
except by statistics." MM. Hardy and Behier {Trait, de Path. Int., 1850, 
t. ii, p. 496;, in speaking of the contest in regard to the propriety of the 
operation, say, "But the question seems now to be definitely settled ; the 
operation has succeeded in fact in a little more than one-fourth of the cases 
io which it has been performed, and, in presence of these results, it may be 
said to become the duty of the physician to have recourse to it whenever, 
notwithstanding an appropriate treatment, the general and local symptoms 
indicate the extension of the false membrane." 

M. Bouchut (Trait, des Mai. de^i XouL-nes, 2c*me ed., p. 316 j says, that 
when medical means have failed, and the disea.se has produced a " state 
lending towards asphyxia, in which an attack of suffocation might cause 
the death of the child, there should be no hesitation ; a new route must be 
artificially opened to the external air; tracheotomy must be performed." 

At the time mrjst of the above expressions were writen, a comp)aratively 
small number of operations had been placed U[>on record in France, but 
they were quite sufficiently numerous to show conclusively that, if the 
operation were carefully performed, and the after-treatment skilfully con- 
ducted, from 25 to 33 per cent, of the cases would recover. This excellent 



106 PSEUDO-MEMBRANOUS LARYNGITIS. 

result is to be in great part attributed to the improvements introduced by 
Trousseau, and subsequently by other operators, both in the mode of per- 
forming the operation, and in the after-treatment of the cases. 

Since the publication of the last edition of this work the operation has 
continued to be so frequently performed in France, that we cannot find 
space to quote the results obtained by individual operators. The aggregate 
of their reports, however, as collected by Koger and See, Chaillou, Barthez, 
etc., yield a result of about one recovery in four in a series of over 500 
cases. 

The proportion of recoveries has varied considerably in different years 
in accordance with the type of the epidemic ; in some years, as 1858, falling 
as low as 1 in 6.9 (124 operations, and but 18 recoveries), while in other 
years it has risen even higher than 1 in 3. 

It is further to be remembered that these French statistics are chiefly 
derived from the reports of the Hopital des Enfants in Paris, and refer, 
therefore, to a poor class of patients, who have in many instances been 
subjected to improper and debilitating treatment before reaching the hos- 
pital, and who are exposed to unfavorable hygienic conditions while in the 
institution. When these unfavorable circumstances are allowed their full 
weight, it must be conceded that the operation of tracheotomy has achieved 
a considerable share of success in France, and has fully justified the elo- 
quent and enthusiastic advocacy of Trousseau. 

In America, tracheotomy has been resorted to but rarely until within 
the past few years. The statistics which have been lately published, how- 
ever, fully sufiice to show that, in the hands of American physicians, it 
has been very nearly, if not altogether, as successful as it has abroad. Dr. 
H. H. Smith ( Oper. Surg., 2d ed., vol. i, p. 473) gives the results of 26 
operations performed in this country, of which 9 recovered. Dr. Gay 
{Boston Med. and Surg. Jour., Jan. 27, 1859, et al.) reports 13 operations, 
with 7 cures and 6 deaths ; and other operators in Boston have performed 
the operation in all 15 times, with 7 cures and 8 deaths. But by far the 
most extensive statistics have recently been published by Dr. A. Jacobi, 
of New York (Amer. Jour, of Obstet, May, 1868, pp. 13 to 65), derived 
exclusively from the practice of physicians in that city. 

The following table shows the results obtained : 

Operator, 

Jacobi, 

L. Vo?s, 

E. Krackowizer, . 

W. Von Eoth, . 

Total, 

In this city the operation has been as yet but seldom resorted to, and 
with but moderate success, owing to the fact that in nearly every instance 
it has been postponed until the child was almost moribund. The follow- 
ing table embraces certainly the great majority of the operations that have 
been performed ; for a knowledge of which we are to a great extent in- 









Percentage 


No. of cases. 


No. 


of cures. 


success. 


67 




13 


. 19^ 


43 




10 


. 23^ 


55 


. 


16 


29 


48 


. 


11 


23 






— 




. 213 




60 


23^ 



I 



TRACHEOTOMY 



STATISTICS. 



107 



debted to the courtesy of the operators, since but few of them have as yet 
been placed on record : 



Xanie of operator. 


No. of cases. 


Xo. of cures. 


Physick, 


2 





Goddard, . 


2 





Pajje, . 


1 





J. Paneoast, 


6 


3 


R. J. Levi?, . 


14 


2 


T. H. Baohe, 


1 





A. Hewson, . 


1 





H. Lenox Hodge, . 


9 


2 


J. H. Packard, . 


3 





T. J Morton, 


3 


2 


GfK>dman, 


3 


1 


Drysdale, . 


9 


3 


Total, . 


. 54 


. 13 or 5 



13 or 24.07 per cent. 

Finally, to sum up the statistics given above, although even this aggre- 
gate does not include by any means all recorded cases, Jacobi states (loe. 
cit.), that out of 1024 operations of tracheotomy, performed in various 
parts of the world, but principally in Europe, 220 or 21.48 per cent, re- 
covered. 

It is evident, therefore, that wherever this operation has been practiced 
in tru^ croup, a considerable proportion of cures has been effected; but in 
order to form a clear opinion as to the real merits of the operation, it is 
necessary to have some idea as to the number of subjects that might have 
recovered without a resort to it. 

This is ver}' easily arrived at in this country, since we believe that it is 
never performed here except as a last resort, when the patient is manifestly 
in great danger of death, or absolutely moribund. 

In regard to the French operations, it is not so clear whether some of 
the patients, who recovered after the operation, might not have been so 
fortunate without it, particularly as M. Trou.sseau formerly recommended 
that it should be performed so soon as we can be certain that the larynx 
contains false membrane.*. But then it is generally understood that he 
was not called to many of the cases upon which he operated until all other 
means had failed, and the child had fallen into an apparently hopeless 
condition. To elucidate this matter, we shall quote the statements made 
by M. Valleix, one of the most accurate and impartial of writers. M. 
Valleix (foe. cit., p. 388-9) tells us that he collected together 54 cases of 
undeniable, well-marked true croup, treated without the operation, and 
found that 17 had been cured. Then, examining what had occurred in 
regard to the operation, he found, as M. Brichetcau had done before, that 
nearly 1 in 3 had recovered, a success almost precisely the same a«* had 
taken place in the ca«es treated by me<liral means alone. " But," he goes 
on to remark, "there is a consideration of very great importance, one which 
gives an altogether different value to tracheotomy, to wit, that in the im- 
men.«e majority of instances, the operation wa.** performed under the most 
discouraging circumstance?, and only when all other methods of treatment 



108 PSEUDO-MEMBRANOUS LARYNGITIS. 

had proved useless, aod the severity of the symptoms, and the near ap- 
proach of asphyxia, indicated impending death So that it follows 

that tracheotomy should be regarded, in connection with croup, as a genu- 
ine medical victory, the honor of which belongs to M. Bretonneau, and all 
preconceived views should fall before the actual facts." We have here the 
evidence of a most competent witness, living on the spot, to convince us 
that the operation is not resorted to in France, at least generally, early in 
the disease, but is performed only as a last resource, when the chance for 
the patient from the efforts of nature, or from medical means, is almost 
null. How, then, can we resist the conviction that tracheotomy does afford 
a sufficient probability of success, after other means have failed and death 
is fast approaching, to render a recourse to it at least justifiable, if not 
almost compulsory ? 

The second point to be examined in discussing the propriety of the oper- 
ation is, whether it be in itself dangerous. 

From the opinions expressed by authors upon this subject, it appears 
that the only serious danger attendant upon the operation is the occurrence 
of haemorrhage. When performed for the removal of foreign bodies from 
the air-passages, the patients almost always recover if the foreign body do 
but escape. M. Ollivier (Art. Larynx, Corps Etrangers, Did. de Med.') 
says that the -success of the operation is, so to speak, certain, when it is 
performed early. Liston disapproves of the operation in croup, but states 
that it is not attended with much danger. Skey regards it as an' opera- 
tion of some difficulty and danger, from the irregularity in the distribution 
of the vessels, and the existence of numerous veins which may bleed pro- 
fusely. M. Boyer does not regard it as dangerous, and states that the only 
danger is from the occurrence of venous haemorrhage into the trachea, and 
not from the amount of blood lost. Chjelius says that it is dangerous below, 
the cricoid cartilage from anastomosis of the thyroidean arteries, from the 
presence of venous plexuses, and sometimes from a deep thyroidean artery. 
Velpeau speaks of the venous haemorrhage as alone dangerous. Trousseau 
states that he has performed it more than 200 times, and has met with but 
a single fatal accident in all of these. Dr. Pancoast, of this city, who has 
operated in more than 6 cases of croup, and a number of times for the re- 
moval of foreign bodies in the air-passages, has never met with any serious 
difficulty in the performance of the operation, nor with any accident which 
he could suppose might have affected the life of the patient. Dr. H. H. 
Smith {op. cit., p. 474), when commenting upon the great disparity of the 
mortality after tracheotomy, when performed for removal of foreign bodies, 
and when for the relief of croup, remarks that it is very evident that the 
dangers which ensue upon incising a healthy trachea are comparatively 
slight, and that the great mortality which has attended the operation when 
performed for the relief of croup, must be due to some other cause than the 
mere incision of the windpipe. 

If, then, it is the uniform testimony of those experienced in the matter 
that the operation is in itself alone but slightly dangerous to life, so that 
its performance adds but little to the danger of the patient ; if it affords 
immediate relief to the suffocation which threatens to be soon fatal, and at 



TRACHEOTOMY — ESTIMATION OF ITS VALUE. 109 

least gives additional time, during which the gravity of tlie disease may 
subside; it", further, as we think has been most conclusively shown by the 
statistics quoted, it has unquestionably saved the lives of a considerable 
number of those upon whom it has been performed, it is difficult to avoid 
the conclusion that it is our imperative duty to resort to the operation 
under certain circumstances. 

That some who have been operated upon might have recovered without 
it, is highly probable ; but the uncertainty as to the absolute necessity of 
reporting to it in any individual case is not even so great, probably, as that 
which exists in regard to many other surgical operations, and to many 
medical applications. 

Our own plan, then, is to try fiiithfully all medical means ; and, being 
satisfied of their powerlessness and of the certainty of a fatal issue to the 
case without the performance of tracheotomy, to inform the parents of the 
inability of mere medical means to afford relief, and to propose the opera- 
tion to them, setting before them the great probability of its not averting 
death, but still strongly pointing out the fact that it does not add to the 
danger of the case, but gives so much additional chance for life that about 
1 in every 4 operated upon recovers. 

Should they throw the whole responsibility upon us, we should, without 
hesitation, advise the operation. Our grounds for so doing are very simple, 
and have been before indicated. The operation does assuredly frequently 
save life. It is not in itself attended with any great danger. It cannot 
increase the danger of the patient's position, but certainly gives an addi- 
tional chance of escape from the disease ; and, lastly, it mitigates, in a re- 
markable manner, the sufferings of the patient. On several occasions, 
indeed, we have been told by the parents, after the death of their child, 
^hat they were very glad it had been performed, since, at all events, it had 
removed the frightful gaspings and strugglings for breath which had pre- 
viously convulsed the whole frame of the poor little sufferer, and had 
rendered his last hours easy and tranquil. 

If we decide that tracheotomy is justifiable, it becomes all-important to 
determine the period of the disease at which we should have recourse to it. 

M. Trousseau formerly laid down the rule that it was to be performed 
80 soon as it was certain that false membranes had formed in the larynx. 
He fixed upon this as the proper moment, because he believed that death 
was, under these circumstances, almost inevitable without the operation. 

This opinion is, however, readily proved to be* untenable. We have 
already learned from M. Valleix that of 54 perfectly well-marked cases 
collected by himself, treated medically (without the operation), 17, or 
about a third, recovered. If we add to this that, of 35 cases seen by our- 
selves 15 recovered without the operation, it becomes very clear that the 
mere presence of the exudation in the larynx is not sufficient warrant for 
a resort to the operation. 

Accordingly, most authorities advise that we should wait until medical 
means have been fairly tried. Thus, MM. liilliet and Barthez (op. cit., t. 
i, p. 340;, in di.scussing the period at which the operation ought to be [)er- 
formed, conclude that it should not be resorted to until the means that have 



110 PSEUDO-MEMBRANOUS LARYNGITIS. 

succeeded in other cases have been fairly tried, and it has become evident 
that they must fail. They advise the practitioner not to wait, however, 
too long a time, but to operate even early should the patient suffer a par- 
oxysm of suffocation so severe as to make it probable that another might 
prove fatal. So, too, Mr. James Spence, in a valuable paper on tracheotomy 
{Edin. Med. Jour., Feb. 1860), states, as the result of his large experience, 
" that if, in a case of croup, all measures have been actively tried, if the 
hard, ringing cough has become suppressed, and the respiration is evidently 
imperfect, as shown by the contracted and depressed appearance of the car- 
tilages of the ribs, and the occasional severe paroxysms of dyspnoea, the 
operation is fully warranted. When the paroxysms become more and more 
frequent, and when the dyspnoea is rather persistent than paroxysmal, with 
turgid or pale lividity, the operation is the little sufferer's only chance for 
life." 

The same course is, we believe, universally pursued in this country, and, 
as the reader will recollect, corresponds precisely with the advice given in 
our remarks on the medical treatment of true croup. 

The prime indication for the performance of the operation is, then, the 
degree of laryngeal obstruction as shown by the characters of the respira- 
tion, the cry, and cough. 

It should, however, be carefully borne in mind that great dyspnoea, or 
even asphyxia, when intermitting, do not so imperatively claim operative 
interference, since cases where the dyspnoea is of this character may re- 
cover without the operation. 

When, however, despite the use of all medical means, an'd especially the 
repeated administration of emetics, the dyspnoea grows steadily and pro- 
gressively greater ; when there is marked hissing laryngeal stridor, and, 
at each inspiratory effort, recession of the base of the thorax ; when, in, 
addition, the voice is w^hispering or suppressed, and the cough short, 
smothered, and muffled, the operation should, we think, be unhesitatingly 
performed. 

In thus defining the conditions under which tracheotomy is called for in 
croup, it is clear that we are not to be influenced at all by the mere period 
of the disease as measured by time, but that, whenever the above symp- 
toms are present, the operation is indicated. 

There can be no doubt, however, of the far greater success of the opera- 
tion when performed in the early period of the attack, before the patient's 
strength is materially impaired ; and it is, therefore, highly desirable that 
the indications which render its performance necessary should be appre- 
ciated so soon as they appear. 

A still further argument in favor of the timely performance of the 
operation is adduced by Dr. George Johnson {British Med. Jour., Jan. 
15, 1870), who dwells upon its value at an early stage, when the indica- 
tions are present, on account of the danger of oedema of the lung from 
venous congestion, and of the coagulation of the blood in the pulmonary 
artery. 

Trousseau, also, in his last publication upon this subject {Clin. Med., 2d 
ed., t. i, p. 450), speaks as follows : " I wrote in 1834, and repeated in 1851 : 



II 



TRACHEOTOMY — CONTRAINDICATIONS. Ill 

SO long as tracheotomy was not a trusty weapon in my hands, I said, we 
should operate as late as possible ; but now that I can number many suc- 
cesses, I say, we should operate as early as possible. In removing from 
this assertion whatever may seem too absolute, I still affirm it, by saying, 
that the chances of the success of the operation are so much the greater in pro- 
portion as it has been the earlier performed.'' 

Notwithstanding this, however, should we be called to a case where the 
last stage of asphyxia has been reached, it is still not too late to perform 
the operation. Thus, in one of the cases that occurred in our own practice 
and which ended favorably, this condition was fully developed, and the 
bluish skin, drowsiness, and insensibility to pain, showed that the patient 
had already sunk into very advanced asphyxia. 

Perhaps we cannot do better in closing our remarks upon this point than 
to quote the concise and forcible axiom laid down by Archambault : "We 
should never operate too late ; it is never too late to operate, so long as 
death is not actually present." 

There are, however, certain conditions which have been thought by 
many authorities to contraindicate the performance of the operation, even 
under the circumstances above described. The first of these is the very 
early age of the patient, and it has been advised to refuse the operation 
in all cases occurring under the age of two years. It is unquestionably 
true, as might be expected, that age exercises a most powerful influence 
upon the prognosis after the operation, owing partly to the difficulty in 
performing it on account of the narrowness of the trachea and the short- 
ness of the neck, but chiefly to the deficiency of vital power, and to the 
difficulty of nourishing the infant afterwards. Notwithstanding these 
influences, which render the prognosis so unfavorable in tracheotomy be- 
fore the age of two years, there are so many successful cases on record 
that the most tender age can no longer be regarded as a positive contra- 
indication. The following list embraces the names of the operators and 
the age of the infants in the cases which have been successful at a very 
early age : 

Baizoau, . . .at 10 months. 1 Vigla, . . .at 17 months. 

..." 1.3 " 'Putain, . . " 18 " 

" (in hands of his i MoutHrd-Mariin, . " 18 '« 

colleague), " 15 •' i Trousseau, . " 18 " 

I>ambert, . . . •• 16 «• I Barthez, ..." 13 



Archambault, . . ♦* 13 

. . " 18 

Roc.r. . " 19 



Maslieurat Lagemand, *' 23 



In adult-, (Ml iML' other hand, tracheoiomy m cruup i.- lo.'^s sucecs-ful tlian 
in children, probably because, a-s Trous.seau suggests, the form and size of 
the larynx allow the pseudo-membrane to extend deeply into the broucliia 
before producing the symptoms of croup. 

There is another condition which, it is thought by many, ought to con- 
stitute an insuperable bar to the operation, and the possible exi.-tence of 
which, in any case, is one of the moat iierious objections that has been 



112 PSEUDO-MEMBRANOUS LARYNGITIS. 

brought against its performance. The condition to which we allude is the 
presence of pseudo-membranous exudation in the bronchia. 

The existence of this condition must greatly lessen the chances of a suc- 
cessful operation, but that it renders success impossible, as has been sup- 
posed, cannot be admitted. MM. Rilliet and Barthez {op. cit., 2eme ed., 
t. i, p. 338) say: "It has been said that one contraindication was the pres- 
ence of false membrane in the bronchia. But, besides the fact that the 
symptoms denoting its presence are uncertain, we cannot see in this a posi- 
tive objection to the operation. Recovery has been known to occur, in 
effect, after the rejection of bronchial false membranes, and we were our- 
selves witnesses of a remarkable example of this kind. And is there any 
better mode of facilitating the escape of foreign bodies than by opening to 
them a passage below the larynx ? Under such circumstances, we must 
expect to be sure, a greater mortality than under more favorable conditions. 
This opinion is, moreover, that of M. Bretonneau." Numerous cases are 
indeed on record, and we have ourselves met with such, where, after the 
operation, large membranous casts of the trachea and bronchia, which 
could certainly never have escaped through the larynx, have been dis- 
charged through the tracheal opening, and their escape followed by com- 
plete recovery. 

It appears evident, therefore, that if in such cases, when death is even 
more surely imminent than in those instances when the exudation does not 
extend below the larynx, tracheotomy affords even a very slight additional 
chance of recovery, it should be performed despite the fact that the child 
will in all probability die. 

But, apart from this consideration, it must be borne in mind that statis- 
tics prove that the false membrane extends below the larynx in about one- 
third of all cases, and still further, that there are no means by which we 
can with certainty determine in any individual case whether such exten- 
sion has taken place or not. 

It was at one time thought that auscultation might afford the desired 
information, but more careful observation has shown that it is not to be 
depended upon. As already said, in most cases the laryngeal stridor is so 
loud as to mask all chest-sounds, and, even when this does not happen, we 
have frequently observed that no definite and reliable information is to be 
gained from physical examination. The following cases may be quoted, 
out of the number on record, besides several that we have ourselves seen, 
as proving this statement. MM. De La Berge and Monneret {Comp. de 
Med. Prat., t. ii, p. 587) mention a case in which they could. not believe 
that the bronchia contained false membranes, as the vesicular murmur was 
extremely pure and was heard everywhere ; and yet, during the operation, 
a false membrane was drawn out, which represented the trachea and the 
division of the principal bronchia. The child died in 15 hours. 

The late Prof. William Pepper, of this city, reported 2 fatal cases {Sum- 
mary of Trans. Coll. Phys., vol. iii. No. iii, p. 106), in one of which "dis- 
tinct vesicular murmur could be heard throughout the lungs, marked only 
occasionally by sibilant and sonorous rales," a few hours before tracheot- 
omy was performed. The child died 20 hours after the operation, and 



TRACHEOTOMY — CONTRAINDICATIONS. 113 

the exudation was found to implicate the larynx, trachea, the large bron- 
chia, and even some of the smaller ramifications. In the other case, the 
state of the respiration was carefully examined the day before death, and 
not the least respiratory murmur could be heard over any part of the chest, 
and yet, in this instance, the exudation was confined strictly to the larynx; 
not a vestige of false membrane was to be found either in the trachea or 
bronchia. 

Iii a case recently attended by us, where tracheotomy had been per- 
formed, so that all laryngeal stridor was absent, auscultation, eight hours 
before death, revealed quite strong respiratory murmur, much obscured by 
snoring bronchial rales. The autero-lateral parts of the chest were alone 
ausculted. Death occurred somewhat suddenly from the lodgment of a 
very large tubular membrane from the left bronchus in the trachea ; and 
at the autopsy there was a tubular membrane found extending throughout 
the trachea, and through the right bronchus to its third divisions. The 
left lung was collapsed and congested ; the right one distended and em- 
physematous. 

Since, then, we can learn little or nothing from auscultation, or any other 
means, as to the presence of false membrane in the bronchia, the question 
becomes one of expediency, so far as this contraindication is concerned., 
whether to leave two-thirds of the patients, many of whom could certainly 
be saved by the operation, to perish without an eflfort to save them, because 
one-third viwst probably die ; or to perform the operation, with very little 
prospect of success in one-third, for the sake of the chance of saving many 
of the remaining two-thirds who must otherwise perish. 

The presence of pneumonia is also universally recognized as greatly les- 
sening the chances of recovery after tracheotomy. It must be borne in 
mind, in regard to this point, that pneumonia is frequently overlooked, 
and indeed that it frequently cannot be recognized on account of the loud 
tracheal rales which hide all auscultatory sounds; while, on the other 
hand, it^ presence may be simulated by the occurrence of collapse of some 
portion of the lung, owing to occlusion of the bronchus leading to it. 
Millard suggests that the degree of dyspnoea may be of service as indi- 
cating the presence or absence of pneumonic complication. Thus he has 
found that in croup not thus complicated the rate of respiration is from 32 
to 48, while, when pneumonia is present, it rises above 50. It is probable, 
also, that by a careful study of the temperature, the occurrence of pneu- 
monia may be suspected by a marked elevation of several degrees. Pneu- 
monia of one lung is not, according to Guersent, a contraindication, nor 
is even double pneumonia regarded by some operators as absolutely inter- 
dicting the operation, though at the same time we are not aware of a single 
instance in which it has been successfully performed where this condition 
was unquestionably present. 

Another condition in which tracheotomy is thought by many to be con- 
traindicated, is when membranous croup occurs as a secondary affection, 
during the course of some constitutional disease other than diphtheria, as, 
for instance, scarlatina, measles, or pertussis. Such cases were regarded 
even by Trousseau as absolutely unfit for operative treatment. Still, that 

8 



114 PSEUDO-MEMBRANOUS LARYNGITIS. 

this contraindication, although of the greatest weight, does not entirely 
forbid tracheotomy, is shown by a case of croup following scarlatina, in 
which Dr. Voss operated, and the child survived 31 days, the tracheal 
wound being nearly closed. Millard, also, in his excellent essay on tracheot- 
omy {De la Tracheotomie dans le Cas de Croup, Paris, 1858), records 3 cases 
of croup secondary to measles, successfully treated by operation. He re- 
gards croup occurring in the course of pertussis as far less unfavorable, 
since the violent cough favors the expectoration of the false membranes. 

There remains, finally, one condition to be indicated in which the ope- 
ration is, in the almost unanimous opinion of authorities upon this question, 
absolutely contraindicated. We refer to the cases of profound general 
diphtheritic infection, where the danger of the child depends upon the 
constitutional disease, even more than upon the laryngeal obstruction, 
where the blood is gravely altered, and the well-known tendency exists to 
the formation of pseudo-membranes upon all abrasions or wounds, so that 
in all probability the operation would merely serve to invite the Extension 
of the exudation. 

Trousseau opposes the operation under such conditions, in the following 
words : " If the diphtheritic infection have profoundly attacked the con- 
stitution ; if the skin, and especially the nasal passages, are occupied by 
the specific inflammation ; if a frequent pulse, delirium, and prostration 
show the system to be deeply poisoned, and if the danger is rather from 
the general condition than from the local lesion of the larynx and trachea, 
the operation ought never to be attempted, for it is invariably followed by 
death." 

Even under this most unfavorable of all conditions, however, there are 
not wanting some operators of wide experience, who still recommend the 
operation : thus Jacobi (loc. cit.) asserts, that whenever the indication of 
suffocative dyspnoea, steadily increasing and not relieved by emetics, ex- 
ists, he would operate despite any complications, general diphtheria, or 
anything else, and uses this powerful language : " Seeing a person sus- 
pended by the neck and being strangled, we should hardly investigate the 
propriety of cutting the rope from the point of view that the sufferer 
might be or is affected at the same time with tuberculosis, cancer, or dia- 
betes." 

After a careful review of the entire question, we believe that the facts 
upon record justify the following conclusions : that the condition of success 
which excels all others is the predominance of the characters of asphyxia; 
that when these are so marked that death is imminent, the operation is 
justifiable despite any complications which may coexist, save perhaps the 
presence of grave general diphtheritic infection ; and finally that, when no 
such contraindication is present, and the dyspnoea is continuous and in- 
creasing despite all other treatment, the operation is positively indicated, 
and it becomes the duty of the practitioner to recommend its performance, 
and, if the decision be intrusted to him, to unhesitatingly assume the re- 
sponsibility of operating. 

We have already indicated with sufficient clearness the influence which 
the age of the patient, the period of the disease, and the character of the 



TRACHEOTOMY — MODE OF PERFORMING THE OPERATION. 115 

epidemic exert upon the results of tracheotomy. But we would again al- 
lude to the marked manuer iu which the result is modified by the charac. 
ter of the previous treatment, and to the fact that its success is very much 
interfered with by the earlier employment of any debilitating measures, 
such as were, until lately, but too frequently adopted. 

We have more than once been asked by the parents of children, upon 
whom tracheotomy was about to be performed, or who had actually un- 
dergone it, what influence would be exerted by the eflJects of the operation, 
should it be successful, upon a subsequent attack of croup ; and since, as 
has already been seen from the cases quoted by us from our own experi- 
ence, second attacks of croup are not very rare, it is interesting to know, 
that so far the statistics which bear upon this question tend to show that a 
previous attack of croup cured by tracheotomy is a favorable condition 
for its performance in a subsequent attack. Thus of 5 cases, collected by 
Millard, in which the operation was performed for the second time, every 
one recovered. The second operation was uniformly found much easier, 
on account of the cicatrix of the former incision serving as a guide, and 
also on account of the slight amount of the hicmorrhage. 

Mode of Performing the Operation. — Tracheotomy being an oper- 
ation which all physicians, whether experienced or not in the use of surgi- 
cal instruments, are liable to be called upon to perform at a moment's 
Dotice, no apology is needed for the introduction here of the details of its 
performance. The following account is in great part borrowed from the 
pages of that most experienced tracheotomist, Trousseau,^ and from a very 
complete and practical discussion of the operation by F. Howard Marsh, 
Esq.' 

The child should be carefully wrapped up, so as to avoid all exposure 
to cold ; and if an anaesthetic is to be employed, should be allowed to sit 
or lie in any position he may choose during its administration, as the con- 
strained position necessary during the operation tends to increase the diffi- 
culty of breathing. He should then be placed upon a table, furnished 
with a thin mattress, and a folded pillow or roll of cloth should be placed 
under the shoulders and back of the neck, so as to put the skin of the 
throat upon the stretch, and render the trachea prominent. If the opera- 
tion is performed during the day, the table should be drawn close to the 
window, and the patient's face directed toward it, so that a full light may 
fall upon the throat; if, however, it be at night, and there is not suflicient 
gaslight, a special as.«istant must be intrusted with the duty of holding the 
candles or lamp. An assistant is also needed to stand behind the patient 
and hold the head securely ; and another, whose duty shall be to draw 
aside the successive layers of tissue and the bloodvessels with a hook, and 
to .«ponge the wound from time to time. 

The instruments needed are a sharp-pointed, slightly curved bistoury ; 
a blunt-pointed bistoury ; two flexible hooks ; a dilator to stretch the inci- 
sion in the trachea so as to favor the introduction of the canula, and made 

* Clin. Med., 2ime ed., torn, i, p. 414 ft seq. 
« St. Barth. Ho«p. Rep., vol. iii, p. 831 ct seq. 



116 PSEUDO-MEMBRANOUS LARYNGITIS. 

like a pair of curved dressing forceps, with a little spur projecting back- 
ward, so as to catch in the tissues and prevent its displacement ; and finally 
a cauula. The size and form of this canula are matters of great impor- 
tance ; and of late years several marked improvements have been effected 
in them. The calibre of the canula should, as first clearly directed by 
Trousseau, be as large as possible without interfering with its easy intro- 
duction into the trachea, and its curve should be that of a quarter of a 
circle. 

In regard to this very important question of the size of the canula, we 
are indebted to Mr. Marsh {loc. cit.) for a series of observations, which 
appear to indicate that a tube somewhat smaller than that recommended 
by Trousseau, Fuller, and others, may be equally eflScient and yet less 
irritating. By a series of careful measurements of the respective diam- 
eters of the trachea and cricoid cartilage, he established the fact that the 
latter diameter is almost invariably less than that of the trachea, to an 
extent varying from ^^gth to 4''ottis of an inch. If, therefore, as his meas- 
urements show, the diameters of the trachea are as follows : during the first 
two years of life, ^jo'ths of an inch ; in the third year, :jQths ; in the fourth 
and to the seventh, ^Jths ; in the eighth and ninth, :^f ths ; and in the tenth, 
^Jths ; it will be seen that a canula having a diameter of /gths of an inch 
will answer for children between the ages of 1 and 4 years ; one of ^ths 
for children between 5 and 8 years ; and one of | |ths for children between 
9 and 12 years old. 

It may be added, that after the 12th year the diameters of the cricoid 
cartilage and trachea increase so rapidly, that the canula now usually 
made for adults, with a diameter of ^fths of an inch, is rather small for 
children between 14 and 16 years old. 

The length of the canula should be sufficient to cause it to reach from i 
to 1 inch below the inferior angle of the wound in the trachea. 

The canula must also be double, the outer tube having a broad collar in 
front, with holes through which the band which passes around the neck 
and secures the canula in position, may be passed and tied. It should also 
be furnished with a key, which plays easily in a notch on the upper part 
of the inner tube. This inner tube must so fit the larger one, as to be 
readily removed and replaced, being secured in position by the little key 
above mentioned. 

In some canulas a still further improvement is introduced, by having 
the outer tube and collar merely yoked together by means of two arches on 
the collar, which receive small outjutting bars at the sides of the upper 
extremity of the outer tube, so that this can shift its position according to 
any pressure it may receive. 

There is also a canula recommended by Fuller, called the "bivalve 
canula," the outer portion of which is not a tube, but consists of two nar- 
row lateral blades, which are easily compressed by the finger and thumb 
into the form of a thin wedge, and expand again when the pressure is 
removed. This instrument supersedes the need of any dilator, and has 
the great advantage of being readily introduced. It is evident, however, 
.that it must produce much more irritation while in position than a tubular 



TRACHEOTOMY — MODE OF PERFORMING THE OPERATION. 117 

cauiila, and in addition, ^Yhen the inner tube has been removed, as is fre- 
quently required, its reintroduction causes pain and irritation, from the 
constriction of the mucous membrane which has bulged inward between 
the blades of the outer portion. Mr. Marsh, therefore, advises that when 
there is any difficulty in introducing the canula at the time of the opera- 
tion, a Fuller's tube should be used, but that this should be exchanged on 
the second day for one whose outer portion is tubular. 

Although it is almost the universal practice to introduce a canula at 
the time of operation, its use has been objected to by several good author- 
ities, as apt to cause inflammation and ulceration of the trachea, and to 
favor the development of pulmonary complications; and several plans 
have been suggested for the separation of the edges of the tracheal wound. 
Thus Mr. Adams, of the London Hospital, recommends the introduction 
of a strong metallic wire speculum, such as are frequently used in opera- 
tions on the eyes, and Dr. Pancoast, of this city, employs a pair of blunt 
leaden hooks. 

In addition to the instruments already enumerated, some operators, 
following the practice of the Dublin surgeons, use a hook or tenaculum 
to fix the trachea, whije the incision is being made through its rings. 
This proceeding has certain advantages, especially when it is designed to 
excise a portion of the trachea, or in case of venous haemorrhage, as the 
trachea can be raised above the pool of effused blood and speedily opened, 
which will usually check the bleediuo^. It is also of service in vouno: 
children, because the trachea is then so pliable and yielding, that, unless 
the hook be used, its anterior wall may be easily driven in front of the 
point of the scalpel, till it is nearly or quite in contact with the posterior, 
in which ca«e the latter also may be wounded. Trousseau, Millard, and 
others, however, strongly object to this practice, believing it to be danger- 
ous to so fix the trachea and oppose the movements connected with the 
performance of the function of respiration which is already so much im- 
paired. Our own observation would go to show that, while the advantages 
to be gained from fixing the trachea are undoubted, especially in young 
children, the dangers have been somewhat exaggerated. 

It has been recommended by several high authorities — Lawrence, Car- 
michael, G. H. Porter, Brainard, Fergusson — to excise a small piece of the 
walls of the trachea. By some this has been adopted with the view of 
dispensing with the use of a canula, but it is claimed that, even when one 
is employed, this practice renders its introduction more easy ; that the 
tube fits the oval opening thus made much more accurately than a mere 
slit, produces less pressure upon the edges, and consequently is not so apt 
to cause caries of the tracheal rings. It seems never to be 'followed by 
narrowing of the trachea after the canula has been removed, as might be 
apprehended. 

This practice is followed by Dr. Pancoast, of this city, who, in the case 
he describes, excised an elliptical piece about one-third of an inch long 
and two-tenths of an inch broad, from the front part of the third, fourth, 
and fifth rings of the trachea. As already said, he does not emph)y either 
a canula or dilator, but holds apart the edges of the wound made in the 



118 PSEUDO-MEMBRANOUS LARYNGITIS. 

soft parts over the trachea by means of a piece of thick leaden wire, bent 
so as to form hooks at either end. The wire is of such a length as to fit 
accurately around the neck when the hooked ends are placed within the 
edges of the incision, and thus keep up just sufficient traction in opposite 
directions to maintain the wound open. 

In regard to the operation itself, almost all who have had much experi- 
ence in it direct that it must be performed with great deliberation and 
care. 

The incision through the skin should be made precisely in the median 
line of the neck, and should extend from the cricoid cartilage to a little 
above the sternum. The slight white fibrous line which marks the inter- 
space between the sterno-hyoid and sterno-thyroid muscles should then be 
followed as a guide for the next incision, and the muscular masses drawn 
aside by hooks. 

The trachea is now exposed with the isthmus of the thyroid gland, and, 
occasionally, large thyroidean veins lying upon it, and great care must be 
observed to avoid wounding these on account of the troublesome haemor- 
rhage which is apt to follow. A still further reason for this caution is the 
occasional existence of an anomalous distribution of arteries, by which a 
branch of considerable size, or even the innominate artery itself, passes 
over the trachea directly in the course of the wound. Any bloodvessels 
may be drawn aside by hooks, and the isthmus of the thyroid gland may 
either be treated in the same way, or if it cannot be drawn away far 
enough to allow a sufficient incision of the trachea, may be ligated in two 
places and divided between (Brainard, of Chicago), although, when possi- 
ble, this had better be avoided. The trachea, having been thus carefully 
exposed, should be punctured just below the cricoid cartilage, and the 
probe-pointed bistoury being introduced, and its edge guarded by the nail 
of the index finger of the left hand, the opening should be enlarged down- 
wards to the extent of two or three tracheal rings. 

It usually occurs that there is some haemorrhage during these incisions ; 
but if it be venous and moderate in amount, the opening of the trachea 
should not be deferred, as the re-establishment of respiration will usually 
speedily check it. 

So soon as the trachea is incised, the dilator should be instantly intro- 
duced with the blades closed; and so soon as in position these should be 
moderately opened. Air now enters readily, and there is a discharge of 
mucus, fragments of false membrane, and blood, through the opening. 
The canula should then be introduced upon the dilator as a guide, its en- 
trance being evinced by the increased facility of respiration, and the es- 
cape of mucus and blood through its calibre. A guard of india-rubber or 
a disk of waxed cloth should then be placed between the guard of the ex- 
ternal tube and the skin, to prevent any irritation or chafing, and the 
canula may be fastened in position by a tape passed around the neck. 

Should blood bubble up by the side of the canula, as Geraldes observes, 
the wound in the trachea has been made too large, so that the blood gains 
entrance during inspiration, and a larger canula should be at once substi- 
tuted. 



AFTER-TREATMENT. 119 

It occasionally happens, as in a case related by Trousseau, that the 
trachea is lined by a false membrane, which is partly detached and pressed 
forward by the end of the canula, so that it completely occludes the open- 
ing, and thus even increases the asphyxia. When this occurs, the canula 
should be withdrawn, and an attempt made to seize the false membrane 
with forceps and withdraw it. 

When the operation has been a laborious one, emphysema of the neck 
may be met with, sometimes extending to a considerable distance, and 
causing great disfigurement or even seriously complicating the course of 
the case. It results from a want of parallelism between the cutaneous and 
tracheal wounds, or from marked disproportion between the size of the 
tracheal wound and that of the canula, or, as occasionally may happen, 
from the escape of the canula from the tracheal wound. It has also hap- 
pened that the inflamed and thickened mucous membrane is stretched over 
and driven before the point of the scalpel, and so escapes a sufiicient divi- 
sion. 

It has not been customary to use anaesthetics in the performance of trach- 
eotomy. Fock, however, advises the use of chloroform, and states that he 
has never, even in extreme dyspna?a, found any ill effects to result from 
its employment. At first the dyspnea is increased by the inhalation, but 
anaesthesia is speedily established, and then the breathing becomes much 
calmer than before. Dr. Voss, who has also employed it, reports equally 
favorably of its effects; and Mr. Marsh, who has seen it administered in at 
least twenty cases, believes that, when carefully and slowly given, it is 
most beneficial. It must be remembered, however, that, owing to the as- 
phyxia, the sensibility of the child is usually much blunted, so that, even 
without anresthesia, the operation has appeared to us to cause but little 
pain, and has bpen borne by the little patients with scarcely any struggling. 

After-Treatment. — Immediately after the successful performance of 
the operation, and the satisfactory adjustment of the canula, an almost in- 
credible change occurs in all the symptoms of the patient. The wild rest- 
lessness of the little sufferer, with the agonized, appealing glances at those 
surrounding the bedside, and the frantic clutching at the throat as though 
to tear it open to admit air, the lividity of the surface, the noisy, hissing 
stridor of the respiration, all vanish as though by magic. Very frequently 
the child falls into a placid sleep, the skin and lips regain their normal 
color, and the breathing becomes regular, full, and nearly as silent as in 
health. This calm is not, however, to be of long duration ; there are fright- 
ful dangers still to be undergone, from which nothing but the most assidu- 
ous care and skilful treatment can enable the patient to escape with life. 

It may, in fact, be asserted that the much greater proportion of success 
which has of late years attended this oix'ration, is to.be attributed chiefly 
to the more judicious after-treatment which patients receive. Indeed, 
Trousseau has mostly truly said, with regard to the importiince of this por- 
tion of the management of the cases, that tracheotomy, badly performed, 
but well treated aflerward.s, will end favorably io a third of all cases; 
whereas, tracheotomy excellently executed, but badly treated afterwards, 
will almost invariably be followed by a fatal termination. 



120 PSEUDO-MEMBRANOUS LARYNGHTIS. 

It might, consequeotly, have been added to the contraindications already 
enumerated, that, unless we can secure constant and skilful attendance 
upon the case after the performance of the operation, there can be but 
little hope of obtaining a favorable result. 

Wherever it is in any way possible, the constant presence, by day and 
night, of a physician or student of medicine, should be secured for four or 
five days after the operation. When this is utterly impossible, all of those 
engaged in nursing the case should be carefully instructed how to act in 
the event of any emergency, so that the child shall never be without the 
presence of some one competent and ready to render the prompt assistance 
which is frequently necessary to avert instant death. The details of the 
attention necessary will be given a little further on. 

One of the first points to which careful attention must be paid, is to give 
to the air to be inspired through the canula as much as possible the tem- 
perature and degree of moisture that the air attains by its normal passage 
through the mouth and nose. Various means have been recommended to 
secure this object ; thus a piece of loose coarse sponge, wetted with tepid 
water, and enveloped in a piece of gauze, may be applied over the canula ; 
or, as directed by Trousseau, " the neck of the child may be surrounded 
by a cravat of knitted wool, or a large piece of muslin or gauze, so that 
the patient expires into this thick tissue, and inspires the air impregnated 
by the warm watery vapor which the expiration has just furnished." 

This is the only means adopted by Trousseau ; but we may, in addition, 
by the aid of a spirit-lamp, keep shallow dishes of water evaporating in 
the room, and at the same time employ a thermometer to regulate the tem- 
perature of the chamber, which should be uniformly kept at from 70° to 
72° F., though the air should be changed frequently, so that it may be pure 
and fresh. 

By careful attendance to this clear but long-neglected indication, we not 
only prevent the rapid drying of the mucus in the canula and trachea, 
but, as Trousseau asserts, avoid to a great extent the occurrence of pneu- 
monia or bronchitis as sequelae of the operation. 

In regard to the treatment of the wound itself, we have already alluded 
to the advantage of placing a piece of lint spread with cerate, or a caout- 
chouc ring, beneath the collar of the canula to prevent any irritation of 
the skin. No sutures should be introduced into the skin incision, as the 
efforts during coughing will soon tear them out. Trousseau strongly ad- 
vises that the edges of the wound should be cauterized daily for the first 
three or four days, with solid nitrate of silver, in order to prevent the for- 
mation of diphtheritic deposit. 

It very soon becomes necessary, despite every care to render the inspired 
air moist, to cleanse the inner tube of the coating of viscid, partly dried 
mucus which collects on its interior, and to eflTect this, the inner tube should 
be removed as frequently as is necessary. The frequency with which this 
withdrawal is required varies in different cases, but it may be stated as a 
general rule, that it should be performed from four to twelve times in 
twenty-four hours. 

When the tube is clear, the respiration is almost noiseless, and hence the 



II 



I 



AFTER-TREATMENT. 121 

siiperventiou of Doisy breathing is usually the indication of some obstruc- 
tion in the inner tube, which should immediately be withdrawn and cleaned. 

The drying of the mucus in its interior may be partially prevented by 
dropping, every half hour, a few minims of tepid water into the mouth of 
the canula, and by smearing the inner surface of the tube with pure glyc- 
erin, every two or three hours. Some yeai*s ago,^ Barthez reeommended 
instillations of tepid solutions of chlorate of soda through the canula after 
tracheotomy, in the hope of effecting the softening of the false membranes, 
and their more rapid and complete expulsion. Although he was inclined 
to attribute a beneficial effect to the practice at the time, it appears to have 
since fallen into disfavor even with its originator. 

We have ourselves employed lime-water in several cases, and always 
with obvious relief. We were induced to use it from its well-known sol- 
vent action upon pseudo-membranous exudation, and have generally em- 
ployed it by atomizing warm lime-water through the canula every few 
hours, or so often as the breathing becomes noisy and labored, despite the 
removal and cleaning of the inner tube, from the collection of viscid mucus 
or pseudo-membrane below the end of the canula. The atomization has 
been continued for a moment or two, and has usually excited cough, while 
at the same time it softened the viscid mucus and enabled the child to 
reject it through the tube. So great, indeed, is the relief at times thus 
afforded, that in one case the little patient asked frequently that the use of 
the atomizer should be repeated. In all probability it does good, partly 
by its mechanical action in exciting cough, partly by the softening effect 
of the watery spray, but partly also, we are inclined to believe, by the 
action of the lime upon the mucus and pseudo-membranes. We are also 
in the habit of directing that the child shall breathe, for a few minutes in 
every hour, the steam from slaking lime, though in all probability this does 
not contain an appreciable amount of the lime itself. 

Recently Dr. Bocker of Berlin {Deutsche Klhiik, July 8, 1876) has re- 
ported the very favorable results he has obtained by means of frequently 
repeated inhalations, after tracheotomy, of the spray of lime-water solution, 
of chlorate of potash, or dilute lactic acid. Dr. Burrer, who has adopted 
the same practice, reports eight cases in which these frequent inhalations 
formed part of the after-treatment; of these eight cases only two died, 
while of ten cases, tracheotomies performed by the same operator before 
his adoption of this mode of treatment, seven were fatal. 

It occasionally happens, however, that the breathing becomes noisy and 
obstructed and remains so even after the withdrawal of the inner tube, 
and the use of the atomizer. The cause of the obstruction then probably 
consists in the presence near the end of the canula, either of a collection 
of dried mucus or of a piece of false membrane too large to escape through 
the canula. If, under thase circumstances, an access of dyspnoea should 
ensue, the strings securing the canula should be instantly cut and the outer 
tube withdrawn. If this be followed by the rejection of false membrane 
and a return of quiet respiration, the canula may be returned ; but if there 

1 Bull. G^n. de Tb6r., May 30, 1858. 



122 PSEUDO-MEMBRANOUS LARYNGITIS. 

is reason to fear that the trachea contains false membranes too large to 
escape through the tube, it is better to allow it to remain out permanently. 

Millard {loc. cit.) recommends that the external tube should always be 
removed at the end of twenty-four hours after the operation, when the track 
of the wound is usually patulous, being lined by plastic lymph, and after 
waiting a few minutes for the rejection of false membranes and cauterizing 
the wound, be again introduced. 

In those cases which progress favorably, it soon becomes necessary to 
decide at what date the canula shall be finally removed. It is evident that 
this should be accomplished so soon as possible, as the tube acts the part 
of a more or less irritating foreign body in the neighborhood of delicate 
and imp^n-tant structures, and yet it is only in rare cases that the patient 
can endure its removal before the sixth or seventh day. 

At the end of the fifth day, therefore, the experiment may be tried of 
plugging the mouth of the canula with a little roll of wool, to learn in 
what degree the larynx has become patulous. Should the child be unable 
to take a single respiration, the experiment may be deferred for several 
days, but should breathing be performed through the mouth for several 
minutes, the measure may be repeated daily, in order to gradually accus- 
tom the larynx to a resumption of its function. 

About the seventh or eighth day the tube may be removed for an hour 
or two ; and, if its abstraction be well borne, it may be finally withdrawn 
the following day, and the wound closed by bringing its edges together 
with adhesive plaster. It is very necessary to observe the caution, that 
the canula must never be removed unless some one competent to replace 
it is at hand. It occasionally happens, however, that the larynx remains 
impervious for a much longer time, and cases are recorded in which it 
has been impossible to remove the canula for fifteen, twenty-five, forty- 
four (Trousseau), or even one hundred and twenty-six (Fock) days ; or 
even for months or years. The causes which thus delay the period at 
which the tube can be removed, are summed up by Mr. Marsh (loo. cit.), 
as follows : 

1. Obstruction of the larynx by false membranes, which have been 
known to linger in its cavity for at least fourteen days after the operation. 

2. A chronic inflammation and thickening of the mucous membrane of 
the larynx, which may remain after the acute disease has passed off". 

3. A narrowing or complete obliteration of the passage of the larynx, 
by the growth of granulations above and around the canula. 

4. An impairment or complete loss of those functions of the muscles 
of the larynx which regulate the admission of air through the rima glot- 
tidis. 

5. Adhesions of the opposed surfaces of the vocal cords. 

After the removal of the tube, the wound heals, either by contracting 
from the circumference toward the centre, when air escapes until the very 
last day ; or the tracheal wound first closes, and the cicatrization then ad- 
vances externally. The average time occupied by this process of cicatri- 
zation, is about one mouth, though it may be completed in two weeks or be 
protracted for two months. 



I 



GENERAL TREATMENT. 123 

Among the results which have been known to follow the prolonged stay 
of the cauula in the trachea, are necrosis of the tracheal cartilages, and 
ulceration about the wound, or of the trachea around the cai^uhi, which, 
in several cases, has been followed by fatal haemorrhage. Suppuration 
among the deeper structures of the neck, even extending into the anterior 
mediastinum, has been noticed in a few instances, when the deepseated tis- 
sues of the neck had been much disturbed. 

General Treatment. — Having carefully discussed the management 
of the canula and the treatment of the tracheal wound, it remains to say 
a few words in regard to the general treatment of the patient after the 
operation. 

The most essential point to be secured is, unquestionably, the proper 
alimentation of the child. It is, however, frequently very difficult to in- 
duce it to partake even of the most tempting food. We should endeavor 
to persuade it to take, as before the operation, nourishing animal broths, 
beef tea, milk, custard, chocolate, wine-whey, or weak milk-punch. If, 
however, these are refused, and the child expresses a desire for any other 
digestible article of food — as the breast-meat of fowl, finely minced, or the 
soft portions of oysters, or eggs — the taste should be gratified. Occasionally 
ice cream will be taken willingly, when other food is refused ; or, when both 
wine-whey and milk-punch are rejected, iced wine and water, or brandy and 
water will be relished. Unfortunately, however, it not rarely happens that, 
owing partly to the soreness of the throat and partly, undoubtedly, to the 
pain caused by the canula during the movements of the trachea in deglu- 
tition, the little patient utterly refuses to swallow more than a mere sip 
of iced water. Under such circumstances, so serious a complication is 
abstinence, that Trousseau recommends that it should be forced to take 
a little food. " Do not fear," he says, " to employ intimidation. In such 
cases I have often — assuming an apparent severity, the expression of 
which I have exaggerated — forced the child to eat, and so have prepared 
the way for a recovery, which, without this, seemed to me impossible." 

Even by this means, however, it may be impossible to secure the ad- 
ministration of a sufficient amount of nourishment, and we would then 
advise the use of nutritious enemata, consisting either of the yolk of 
one egg, beaten up in an ounce of milk, or of one ounce of beef tea, and 
given about every four hours. If they appear to irritate the rectum, 
and are not retained, one or two drops of laudanum may be added to 
each enema. 

In comparatively rare casas there exists, in ad<lition to this unwilling- 
ness to eat, a p>sitive difficulty in swallowing liquids. This results from 
the inaction of the vocal cords and epiglottis, whicii allow the fluid to pass 
through the glottis into the trachea and bronchia, causing violent cough 
and escaping through the artificial opening. The child is ho alarmed by 
this that it sometimes refuses all nourishment, and can only be supported 
by nutritious enemata. Under these circumstances, Trousseau advisees that 
all liquid aliment should be interdicted, and that the food of the child 
should consist of very thick sf)up, vermicelli boiled in milk or broth, hard 
eggs, eggs \er\ much cooked in milk, and rare-cooked meat, in rather largo 



124: PSEUDO-MEMBRANOUS LARYNaiTIS. 

morsels. If the thirst becomes ardent, he allows pure cold water, taking 
care to give it either some length of time after, or immediately before, the 
meals, in order to avoid vomiting. This difficulty in swallowing rarely 
begins until three or four days after the operation, and does not usually 
last beyond the tenth or twelfth day. Sometimes, as M. Archambault has 
suggested, the child is enabled to swallow with ease by closing the cauula 
with the finger at the moment of deglutition, but at other times this fails 
entirely. 

In many cases the difficulty in inducing the child to swallow, after the 
operation, is so great that all medication must be suspended, excepting the 
administration of small doses of opium, by the mouth or by enema, which 
we would advise to be continued. 

Whenever it is practicable to give remedies, however — without inter- 
fering with the ability and willingness to take food — it is very important 
to bear in mind that despite the very great relief which the operation may 
have afforded, it has by no means put a stop to the disease, but has simply 
afforded the system another chance to overcome and cast off the constitu- 
tional affection. 

Of course, the use of emetics must be suspended, and so if, on any theo- 
retical ground, any depressing remedies have been employed, they should 
be discontinued. But we should recommend under such circumstances, 
that the use of the combination of chlorate of potash, tincture of chloride 
of iron, and sulphate of quinia, should be persisted in. 

We subjoin the histories of two cases of true croup, which have lately 
occurred in our practice, and which will serve to illustrate clinically the 
remarks that we have made upon this disease. 

In both cases tracheotomy was performed by Dr. H. Lenox Hodge, in 
one instance with complete success, but in the other with a fatal result. 

The first and successful case was under the care of Dr. R. Boiling, of 
Chestnut Hill, and was seen in consultation by Dr. J. F. Meigs, and, sub- 
sequently to the performance of the operation by Dr. Hodge, by Drs. 
Edward Rhoads and William Pepper. 

The second case was visited by both of us from the first ; and was at- 
tended, after the performance of the operation by Dr. Hodge, with the 
most zealous and skilful care, by Drs. Wharton Sinkler and M. Longstreth. 

Angina with Membranous Exudation on Tonsils — Membranous Lai^yngitis : 
Tracheotomy at end of second day — Complete Recovery. 

Case 1, F. W., set. 7^ years, a delicate child, who at the age of 4 years had 
suffered from a severe attack of true croup, from which he recovered without the 
operation. On December 23d, 1868, he was noticed to have the symptoms of an 
ordinary cold in the head, with slight sore throat, some dysphagia, and larj'ngeal 
cough ; he was visited and prescribed for by Dr. E. Boiling. On December 24th 
the cough persisted, and there was slight coryza and redness of fauces, but without 
any membranous deposit or any croupy symptoms. 

He was ordered small doses of Kermes mineral, Dover's powder, and nitrate of 
potash, and counter-irritation to the throat. 

At 5 A.M., December 25th, the child, who had gone to sleep quietly, waked in a 
frightful paroxysm of dyspnoea, gasping, clutching at its throat, and with oppressed 
whispering voice. 



ILLUSTRATIVE CASES. 125 

Emetics of alum were given, and produced free emesis, but without the rejection 
of any false membrane, nor was any yet visible in the fauces. The powders were 
continued. 

The dyspnoea persisted and grew steadily worse; the voice remained suppressed. 
Membranous exudation was noticed in the evening on the tonsils, and during the 
following night the obstruction to respiration became so intense that, after consul- 
tation with Dr. Meigs, tracheotomy was performed by Dr. H. Lennox Hodge. The 
trachea was opened just below the isthmus of the thyroid gland. No false mem- 
brane could be seen at the level of the opening, nor was any rejected. 

A few hours later it became necessary to remove the canula, cut an oval ]iiece from 
the trachea, and replace the tube, during which proceeding artificial respiration had 
to be maintained. 

The neck was surrounded by gauze. Nutritious enomata, with small doses of 
laudanum, were given every two or three hours. Cream and brandy were given 
by mouth, and the attempt was made to give quinia and iron, but the child abso- 
lutely refused to take it. The breathing became somewhat easier, but at 9 a.m., 
December UGih, it was 66, and the pulse 160. 

The internal tube was frequently removed and cleansed of very thick viscid 
mucus, which rapidly collected in it; and the other treatment was continued. In 
the afternoon it became evident that the internal tube was entirely too small, and 
it was therefore abandoned and the external one alone retained. Warm lime-water 
was now atomized down the tube every two hours, and on the first occasion of its 
use was followed by the rejection of a large piece of thick, dark-gray, glue-like 
false membrane. This was followed by marked relief to the dyspncea. 

The child was kept gently under the influence of opium ; and was nourished by 
enemata of beef tea. f Jj ; brandy, f5J ; tr. opii, gtt. iv, given every three hours; 
which were retained unless they provoked a fecal discharge, which happened two 
or three times. The urine was passed freely, and was not albuminous. 

The respirations were conducted solely through the tube and once during sleep 
fell as low as 32. 

Df^rcmher 27. — Still refused to eat, and the bowel also became somewhat irritable, 
so that several of the enemata were rejected. The respirations varied from 35 to 
48; the pulse from 132 to 140. The treatment was continued; the atomization of 
lime-water through the tube being repeated every three hours. Towards the close 
of each interval the face became flushed, and the child grew restless, throwing the 
arms about excitedly, at times leaping up in bed, and turning round so as to lean 
forward on the pillows and bury his face in his hand, or else looking round with 
an apf)ealing expression. The atomization was always followed by cough, and the 
rejection of pieces of false membrane and thick puriform matter. Towards evening 
he began to swallow some food. 

Dtccmh^r 28. — The tissues of the nock had become so much infiltrated and swollen, 
that the canula was no longer long enough to reach from the cutaneous surface into 
the trachea; it wa.s in this way pushed forward till it obstructed the tracheal open- 
ing and caused great dysjinoca. It was consequently removed, and the child, though 
much exhausted, sank into a gentle refreshing sleep, with quiet regular breathing. 
The tube was not replaced, the breathing being readily performed through the 
wound. There was still marked indi?position to take food, and for a few times ho 
wa.s forced to swallow by holding his nose and pouring beef tea down his throat; 
this was not, however, continued, a.« the effort exhausted him very much, owing to 
his most violent resistance. The discharge from the trachea through the wound 
was quite fluid, purulent, and very fetid. A solution of carbolic acid, gtt. x, in Oss. 
of tepid water, was atomized through the wound ; and the atmosphorc of the room 
was kept impregnated by atomizing a stronger solution about the chamber. 

During the day be swallowed more fuo<l ; gr. \ of opium was given twice; his 
circulation and re«pir8tion improved. 

December 29. — Condition still improving. Respirations 28, quite full and deep, 



126 PSEUDO-MEMBRANOUS LARYNGITIS. 

without rales ; pulse bad fallen steadily from 114 to 84, and was more full and strong. 
The color of surface was better. Kespiration carried on partly througb the mouth. 

December 30. — The child passed a very comfortable day. The respirations were 
about 24 ; the pulse 78 to 86, soft, full, and strong ; the capillary circulation good. 
Food was taken much better, the child eating a croquette made soft with cream, 
the soft part of several oysters, a small piece of breast of partridge cut fine and 
rubbed up with butter and salt, and drinking sherry wine and water, and rich 
chocolate. The discharge had lost to a great extent its offensive character. Took 
gr. ss. of opium at night, and slept five hours quietly. 

December 31. — The child's condition was better in every way. The wound was 
contracting, the edges of the tracheal opening white and clean, and granulations 
beginning to project over it. The cough was stronger and more laryngeal, and the 
voice stronger and clearer, though still whispering. A good deal of the discharge 
was now raised into the mouth and expectorated. The gauze with which the wound 
had been covered was changed for a piece of patent lint, to encourage the larynx 
to gradually resume its functions. 

From this time the case steadily improved. The matter expectorated grew more 
and more mucoid, thin, whitish, and scanty, and finally expectoration ceased almost 
entirely. The general symptoms rapidly improved, though he remained weak and 
nervous for six weeks. The external wound was covered with patent lint,- at first 
of one, then of several thicknesses, and he gradually regained the power of breath- 
ing through the larynx, and of speaking. The larynx seemed quite clear after Jan- 
uary 2d, 1869, eight days after the operation. The wound granulated from the 
bottom outwards, and was entirely cicatrized by the end of six weeks ; by which 
time he was about the house, and had returned to his studies to occupy his mind, as 
he was very fretful and nervous. 

November 1, 1869. — F. W. remains perfectly well, and is indeed enjoying more 
robust health than for several years before this attack of membranous croup. 

Angina with membranous patches on tonsils ; Membranous Laryngitis ; Tracheotom,y 
on tenth day ; Death on thirteenth day [jifty-eight hours after operation). Au- 
topsy. — False mem,brane extendiyig from tracheal wound to third division of bron- 
chi ; right lung emphysematous ; left lung collapsed; blood dark and fluid. 

Case 2. K. B., girl, set. 6 years and 1 month; rather tall for her age. Her 
parents are healthy ; but she herself had suffered much from spasmodic asthma 
during infancy and first dentition. Since then she has enjoyed good health. On 
the morning of Tuesday, October 5th, 1869, she appeared unwell with a little croupy 
cough, which passed off in the middle of the day, and she was allowed to play in 
the square for a couple of hours. On Friday, 8th, her cough was worse, but still 
she seemed so bright that she was allowed to play about the room ; but in the after- 
noon she complained of sore throat, and Dr. J. F. Meigs was called and found small 
patches of exudation on the tonsils. 

R. — Potass. Chlorat., gr. ij. 

Tr. Ferri Chloridi, gtt. v. 

Every third hour in a teaspoonful of syrup and water. 

During the night, violent dyspnoea, with noisy gasping breathing, came on, for 
which emetics were employed with some relief. 

On Saturday^ 9th, there were patches of membranous exudation on the fauces and 
tonsils. The cervical lymphatics were only slightly enlarged. The breathing was 
difficult and stridulous ; the voice feeble, small, usually whispering, but when raised 
by an effort was rather piping and shrill ; the cough was short and smothered. 
There was no coryza. Treatment continued, and inhalations of the vapor from 
slaking lime ordered every hour. 



ILLUSTRATIVE CASES. 127 

On Sundaj/, lOM. — The child was restless, with at times marked jactitation ; face 
flushed, and expression anxious ; respiration labored ; inspiration imperfect, with 
shrill stridor ; expiration prolonged and stridulous. No expectoration. Membrane 
siill vi<ilile in fauces. No albumen present in urine. Pulse frequent, skin hot and 
moist. Treatment continued, and cloths wrung out from hot water applied to the 
throat. 

Monday^ Wih. — Condition about the same; the degree of dyspnoea varying 
from time to time with degree of spa?m, but the breathing still continuously 
labored and stridulous. Treatment continued, and frictions with turpentine lini- 
ment directed to be made to the throat. Marked unwillingness to eat. 

Ttifsday, Vlth — There was marked improvement in the ciiild's condition. The 
breathing was easier and less stridulous ; the cough less frequent and looser, with a 
few thick yellowish purulent sputa ; the voice was raised with less difficulty, and 
•was clearer and stronger. There was, however, the same faucial pain and obstinate 
indisposition to eat. The fauces were still red and swollen, and a small thin patch 
of exudation was visible on one of the tonsils. The treatment was continued, and 
the child also look a little port wine and water and beef tea, and had nutritious 
enemata of qz.s, given every four hours. 

Wednesday \Zth. — The condition of the fauces was better, the breathing easier, 
and the voice more clear. The skin was still heated, pulse frequent, and there was 
still indisposition to eat. 

During the ensuing night the breathing again became more oppressed and 
tighter, with some return of stridor. The voice also became suppressed and 
whispering. The circulation was somewhat obstructed, the face becoming flushed, 
and the lips rather dark. 

Thursday \Ath — These symptoms were aggravated, and in the evening there was 
marked jactitation and restlessness. The respirations were 40 in the minute, and 
stridulous, with prolonged expiration ; and, during the inspiratory effort, with vio- 
lent action of the external respiratory muscles, elevation of the shoulders, and 
recession of the base of the chest and of the epigastrium. There was also com- 
plaint of pain at the epigastrium. The cough was infrequent, short, smothered, 
and muffled. The eyes were anxious, staring and prominent, with large pupils. 
The pulse was frequent, 140, and small. 

During the night there was a steady aggravation of all these symptoms. The 
respirations rose to 46, and became extremely obstructed, the recession of the base 
of the chest and at the epigastrium being unusually marked during inspiration. 
The voice was whispering and almost suppressed ; the expression strained, ai)peal- 
ing, and anxious ; the face deeply flushed and the lips livid. There was the same 
complaint of constant pain at the epigastrium. 

Friday loth, at "J A.M., respirations 36, pulse 136. Tracheotomy was performed 
by Dr. H. Lenox H«>dge, the trachea being ojiened just below the isthmus of the 
thyroid gland, and a small oval piece excised from iU walls. A good deal of 
venous haemorrhage occurred during the operation, but stopped immediately after 
the trachea was opened, and the lube adjusted. 

No ansesthetic was used, but the child made no resistance, and evidently was 
slightly benumbed from asphyxia. Soon after the operation the respirations grew 
more easy, a large piece of false membrane was thrown oflT through the opening, 
the flush disappeared from the face, and the features became composed and placid. 

Very soon after the op^-ralion the respirations fell to iJ8, and throughout the day 
remained easy and regular. The pulse fell to about 120. The child slept well, hut 
would eat but little, and still had enemata of beef tea, f^j, q. t. h., given it. The 
air of the room was kept pure, but warm and moist. The canula wan c(»vered with 
folds of gauze moistened with lime-water, and the wound was covered with a piece 
of greased linen, fo as to protect it from the canula. The inner tube wa? romoved 
every hour, cleaned, anointed with glycerin, and returned. Warm lime-water was 
atomized through the tube every three hours, and always produced strong cough- 



128 PSEUDO-MEMBRANOUS LARYNGITIS. 

in<;, with the expectoration of thick purulent matter, and occasionally of flakes 
of tough white false membrane. All medication was suspended, save the ad- 
ministration of gtt. ij, or iij, of Tr. Opii Deodorata sufficiently often to keep the 
child gently under its influence. During the ensuing night the internal tube was 
removed, owing to the difficulty in expelling the thick viscid mucus. 

Saturday^ 16/A.-^The respirations were 24; pulse 116. During the day the child 
took more beef tea and wine and water, but still had nutritious enemata given. 
There was great thirst, and she still complained of pain in swallowing. There 
was no coryza, and very slight, if any, enlargement of the cervical lymphatics. 

Towards evening, breathing again grew obstructed, evidently from accumulation 
of mucus and pseudo-membrane below the end of the tube, which was consequently 
removed. Its removal was followed by the discharge of several large pieces of false 
membrane through the wound, the edges of which were well consolidated by lymph. 
The breathing quickly became noiseless, easy, and tranquil again. During the fol- 
lowing night the child enjoyed some refreshing sleep, and took more nourishment. 
The atomization of lime-water through the tracheal opening was repeated about 
every two hours, and with such great relief that she several times asked for it her- 
self by signs, as it each time provoked cough, and caused the expulsion of thick 
purulent matter, dried mucus, and shreds and flakes of false membrane. Urine 
was discharged freely, and contained no albumen. 

Sunday 11th. — In the morning she appeared quite comfortable. The voice was 
still whispering, but the cough seemed looser, and she expelled purulent matter 
more freely through the opening ; no false membrane was discharged. The thirst 
was still great, but the child took beef tea more freely. The bowels have for seve- 
ral days been opened two or three times daily. Kespirations 20-25; quite full, 
without recession of the base of the chest. Pulse 130-186, of rather better vol- 
ume. Hands fairly warm, though at times there was a little tendency to coolness. 
The wound was evidently contracting. Slight emphysema of the base of the 
neck, which caused complaints of pain about the neck and shoulders. 

At 4 P.M. it was observed that the breathing was again growing obstructed, and 
that there was recession of the base of the thorax during inspiration. Lime-water 
was freely atomized through the opening, but without causing any discharge of 
membrane. The difficulty of respiration increased until 5^ p.m., when suddenly 
symptoms of asphyxia appeared. Prolonged efibrts at artificial respiration were 
made, and life was thus maintained for a short time, but no essential relief was af- 
forded, and death soon followed, on the thirteenth day of the disease and fifty-eight 
hours after the operation. 

The chest was frequently ausculted throughout the course of the case. Before the 
operation it was impossible to isolate any respiratory murmur, owing to the loud, 
snoring, whistling, and cooing tracheal and bronchial rales. After the operation, 
and still more after the final removal of the canula, a faint respiratory murmur 
could be detected, mingled with the above rales. On the morning before death 
only was there an obscure flapping sound transmitted to the ear with the tracheal 
and bronchial rales, but even then it was indeterminate in character. 

During the efforts at artificial respiration, a long tubular false membrane was 
ejected. It had evidently been the immediate cause of death. 

Autopsy, twenty-four hours after death. Brain not examined. 

Thorax and Air-passages. — The wound in the neck looked well, without pseudo- 
membranous exudation. The larynx itself could not be examined. A long false 
membrane, extending from the tracheal opening down through the right bronchus 
to the third or fourth division, lay loose in the trachea, having been detached from 
the mucous membrane. In the bronchia it was still slightly attached, but sepa- 
rated readily on traction. It was firm, very tough, and white, and, in the upper 
part of the trachea, at least one line thick. Below the bifurcation it was tubular 
for the rest of its course ; and in its terminal portions grew softer and more yellow- 
ish. There was also, in the trachea, a large patch (1^ inches long by ^ inch wide) 



DISEASES OF THE LUNGS AND PLEURA. 120 

of false membrane, of dull white color, and tightly adherent. Upon raising it, 
numerous little delicate fibrous prolongations were seen attaching it to the mucous 
membrane. Beneath this patch the mucous membrane was deeply reddened, dry, 
excoriated-looking, and slightly roughened by minute elevations. There was no 
enlargement of the mucous follicles. The vascularity of the mucous membrane di- 
minished in the lower part of the trachea, and was but slightly marked in the sec- 
ondary divisions of the bronchi. No ulceration was seen at any point. There was 
no pseudo-membrane in the left bronchus or an\' of its branches, and the mucous 
membrane here was less reddened than on the right side. In all probability the 
false membrane removed immediately after death had come from the left bronchus. 
The right lung was largely distended, the posterior border dark and congested, but 
the rest of the organ pale and emphysematous. The left lung was dark, purplish, 
non-crepitant, collapsed, and yielded on section an abundant flow of dark, airless, 
bloody serum. No pleurisy or pleural effusion. 

Heart. — The left ventricle was very firmly contracted and empty, and the tissue 
of its walls hard, tough, and florid red. The walls of the right ventricle were re- 
laxed, and the cavity filled with fluid dark blood, without any clots. No excess of 
pericardial efl'usion. 

The liver and kidnevs were gorsjed with dark blood. 



CHAPTER 11. 

DISEASES OF TPTE LUNGS AND PLEURA. 
GENERAL REMARKS. 

It would be difficult, perhaps, to overestimate the importance to the 
medical practitioner of a thorough kno^yledge of the different diseases of 
the lungs and pleura, as they occur in children. The diseases of the respi- 
ratory organs — and much the most frequent of them are pneumonia and 
bronchiti.s — cau.se, according to West, very nearly a third of all the deaths 
under five years of age in England; while not above one child in four dies 
under that age from diseases of the nervous system, and not above one in 
seven from those of the digestive system. In this country, it would seem, 
from the bills of mortality, that a larger proportion of children die of di.s- 
eases of the digestive than of the respiratory system. But, while this is 
true, there can be no doubt that the diseases of the latter system are de- 
serving of our utmpst attention, since not only are they of constant occur- 
rence and of fatal tendency, as idiopathic affections, but since, al>«o, they 
frequently appear as complications in the course of other di.seases, adding 
greatly thereby to their severity and danger. In measles, for instance, 
by far the most frequent cau.se of danger is the occurrence of some inflam- 
mation of the lungs or pleura. In .scarlatina and typhoid fever, bron- 
chitis and pneumonia are very common accidents, and recent researches 
have shown that in hooping-cough, and in all states of great debility and 
prostration, a certain change in the condition of the pulmonary tissue, to 
which the term collapse has been applied, is ver}* apt to occur. 

9 



130 CONGENITAL ATELECTASIS. 

The morbid condition of the lunj? last referred to, that of collapse, is 
one that has been well understood only within a few years past, and yet it 
is so important a one, in a practical point of view, as to excite a feeling of 
surprise that it had not been discovered before. 



AKTICLE I, 

ATELECTASIS PULMONUM, OR IMPERFECT EXPANSION OP THE LUNG. 

The title of atelectasis pulmonum, from areAvyi?, imperfect, and exTaaiq^ 
expansion, was first employed by Dr. Edward Jorg, to designate a con- 
dition of the lungs observed by him in new-born children, a condition in 
which larger or smaller portions of those organs had never been penetrated 
by air. The respiration of the infant had, in such cases, been only im- 
perfectly established at birth, and some parts of the pulmonary tissue had, 
consequently, never undergone expansion under the distending influence 
of the inspiratory act; these undilated parts continued in the foetal state. 

In addition to this congenital form of imperfect expansion of the lung- 
tissue, this condition is met with at all ages of life, though with especial 
frequency in young children, as the consequence of a collapse of portions 
of the once-expanded lung, or, in other words, of their return to the foetal 
or unexpanded state. To this latter form of imperfect expansion, the 
terms post-natal atelectasis, collapse, and foetal condition have been given. 
Before the discovery of its real nature was made, it had often been de- 
scribed also under the well-known names of carnification and lobular 
pneumonia. We shall designate it by the title of collapse or post-natal 
atelectasis, while under that of congenital atelectasis pulmonum, we shall 
describe the congenital variety of imperfect expansion. 

CONGENITAL ATELECTASIS. 

Anatomical Appearances. — In congenital atelectasis the parts of the 
lung most frequently affected are the posterior portion and lower edge of 
the inferior lobes, the middle lobe of the right lung, and the languette 
and lower edge of the upper lobes. In some instances that we have ex- 
amined, the greater part of the lower lobes of both lungs, while, in others, 
still larger portions of these organs have been found to present this con- 
dition. The imperfectly expanded portions of the lung are of a dark-red 
or purplish color, and are diminished in size, so as to be depressed below 
the level of the healthy parts. They are solid to the touch, and yet they 
have not lost their cohesive properties, as they are neither friable, easily 
torn, nor readily penetrable by the finger ; their cut surface is perfectly 
smooth ; they do not crepitate under the finger, and no air-bubbles are 
seen in the fluid squeezed out by pressure ; they sink when thrown into 
water. They, in fact, resemble exactly the foetal lung. The most con- 



CONGENITAL ATELECTASIS. 131 

vincing proof of the real nature of this condition is obtained by the infla- 
tion of the lung. When this is done, the depressed, hard, and dark- 
colored portions — unless the subject from whom the specimen has been 
taken raay have lived long enough to have allowed the different tissues of 
the lung to become adherent — rise to their natural level, become elastic, 
soft, and crepitating, and change, under the influence of the enter- 
ing air, from a dark and livid tint, to the rosy or pink color of healthy 
pulmonary tissue. In recent cases, this inflation is performed with great 
ease and with perfect success; while in other instances, in which the 
child has lived for some weeks or months, the distension is either effected 
only by strong eftbrts, or in a very imperfect manner, or it may fail en- 
tirely, owing to some permanent change having taken place in the tissues 
of the unexpanded portions. In a case that occurred to ourselves, the 
subject of which died, at the age of fourteen months, of acute pleurisy of 
the right side, after having presented, at birth and throughout its short 
life, many of the symptoms of atelectasis, the inferior two-thirds of the 
lower lobe of the left lung exhibited in the greatest perfection all the 
atelectasial characteristics. The whole of the unexpanded part was dis- 
tended by means of inflation with a blowpipe, but only after repeated and 
powerful expiratory efl^orts ; and Dr. E. Wallace, who made the examin- 
ation, assured us that he was obliged to use a degree of force much greater 
than he ever employed to inflate healthy adult lung. 

In some cases, there are found small patches of vesicular emphysema 
associated with the areas of pulmonary collapse. If, in consequence of 
commencing post-mortem decomposition, there has been any development 
of gas in the tissue of the lungs, it is seen, by the aid of a lens, in the form 
of irregular air-bubbles scattered through the interstitial tissue, which are 
easily distinguished from the minute shining air-bubbles, crowded together 
in regular arrangement, which are seen in lungs which have been inflated. 
— Bouchut, Jour.f. KinderkraJikheiten, 1863, 3-4, p. 263. 

In most cases, the foramen ovale and the ductus arteriosus are found to 
be still open, or the latter has but partially closed. 

The causes of congenital atelectasis have not been satisfactorily ascer- 
tained. The conditions that are probably the most frequent causes are: 
original debility of the infant, from any cause that has interfered with its 
proper development in utero, as feeble health on the part of the mother 
during pregnancy, or multiple pregnancy; and accjuired debility, brought 
about by the fact of the infant's being exposed at birth to unfavorable 
hygienic influences, and particularly to those which interfere with the 
proper performance of the respiratory act, as cold, a vitiated and close 
atmosphere, and the use of too heavy or tight clothing. A very hurried 
and rapid labor ha.s been thought to cause, in some instances, this imper- 
fect expansion of the lung-substance. In a case that occurred to one of 
us (see Am. Jour, MM. *Sc., Jan. 1852, p. 83), the only explanation of the 
condition, which seemed at all plausible, was that the placenta had been 
separated from the uterus at too early a period of the labor, in consequence 
of the violent and rapid character of the latter, so that the child wan for 
a short time before birth cut off* entirely from it« connection with the 



132 CONGENITAL ATELECTASIS. 

raother-^a time sufficient so to lower its vital forces as to bring on a con- 
dition resembling syncope, and to deprive it of the muscular strength 
necessary on entering the world, to produce a full expansion of the thoracic 
cavity, and so of course to effect a dilatation of all parts of the lungs. 

In addition to this, congenital collapse of the lungs may result from the 
air-passages of the child becoming obstructed with mucus or fluid in con- 
sequence of the umbilical cord being ruptured during labor, and an in- 
spiration thus becoming necessary, before the head is free from, the liquor 
amnii or the secretions of the mother's passages. Finally the want of ex- 
pansion has been in some cases found to be dependent on pressure upon 
the medulla oblongata, implicating the roots of the pneumogastric nerves, 
resulting from inflammatory exudation or from effusion of blood owing to 
injuries incurred during delivery. 

Symptoms. — The symptoms depending on congenital atelectasis vary a 
good deal in different cases. There are some, however, which exist in most 
instances. These are the following: the child comes into the world feeble 
and weak, and instead of crying vigorously and loudly the moment or 
very soon after it is born, it fails to cry at all, or the cry is low and weak, 
or it is whimpering or wailing ; the color, instead of being brick-red or 
dark-red, is pale and whitish, leaden, or livid ; the muscular movements, 
which, in healthy children, are strong and vigorous, are in these, languid 
and slow, or there are none or scarcely any, the limbs being relaxed and 
motionless. If the breathing is observed, it is found to be short, high, and 
imperfect, and it is evident that the thorax is but imperfectly dilated at 
each movement of respiration. When these symptoms exist in a very 
marked degree, the infant either dies soon in a state of asphyxia, or, the 
muscular force slowly increasing, the respiration gradually improves, and 
the child is, after a longer or shorter time, either out of danger, or it falls 
into the same state as that of one in whom the symptoms have been from 
the first less severe. Under the latter circumstances, the infant continues 
feeble and weak. It breathes shortly, rapidly, and imperfectly, but often 
without any appearance of effort. The cry is rare, and when heard, is 
low and feeble, or there is with each respiration a constant plaintive moan, 
which is very characteristic, and strongly expressive of exhaustion. The 
color continues pale and whitish, or it is bluish, and the temperature of 
the extremities is lower than natural. The child sleeps the greater part 
of the time, and is unable to nurse or nurses very feebly, but can swallow 
■when fluid is poured into the mouth. In such cases as these, the infant 
does not necessarily die, but will often recover when properly treated. In 
favorable cases, the symptoms just enumerated may last from a few hours 
to a day or two, or even a few weeks, without much change ; then, under 
the influence of correct hygienic and medical treatment, they will often 
begin to improve. The color becomes less pale or less bluish ; the mus- 
cular movements are somewhat stronger; the child begins to cry, and 
in a louder tone ; the act of swallowing is easier and more perfect, or the 
infant is able to suck when applied to the breast, at first feebly and only 
for a moment, and then more strongly ; the respiration becomes slower. 



SYMPTOMS. 133 

fuller, and more Datural, and gradually the dangerous symptoms disap- 
pear. 

lu unfavorable cases, on the contrary, the respiration fails to improve, 
but becomes more and more short, quick, and imperfect; the temperature 
of the body falls ; the color of the surface changes, becoming leaden, 
bluish, or even livid, the change showing itself first in the neighborhood 
of the mouth, and in the hands and feet, and extending gradually to the 
rest of the body; the difficulty in swallowing becomes greater, and very 
generally some spasmodic twitchings begin to show themselves about the 
muscles of the face. The respiration is very often attended with slight 
wheezing or rattling, and the convulsive movements returning frequently, 
and becoming more violent and more general, the child dies in convul- 
sions, or it sinks very slowly and gradually, without convulsions, as though 
in a state of syncope. According to Steffen (Klinik. d. Kinderkr., 1865, 
1 Bd., p. 50), thrombosis of the cerebral sinuses has been found after 
death under such conditions. 

There is another symptom of imperfect expansion of the lungs in new- 
born and very young infants, which ought not to be passed unnoticed. It 
is one mentioned by Dr. George A. Rees, of London, in an essay on this 
subject (London, 1850), and is of much diagnostic value, although not a 
pathognomonic symptom of this condition as regarded by him. It is an 
altered movement of the ribs in respiration. During the inspiratory effort 
the ribs are seen to move inwards toward the mesial line of the trunk, in- 
stead of outwards as in ordinary respiration, thus diminishing instead of 
expanding the transverse diameter of the thorax. The explanation of the 
altered movement is as follows: when the diaphragm descends, the lung 
ought to expand in such a way as to fill up the increased space produced 
in the thoracic cavity by the descent of that great muscle. Instead of this 
being the case, however, the lung is collapsed and inexpansive, and can- 
not enlarge sufficiently to fill up the space alluded to, so that there would 
remain a vacuum in the chest were it not that the thoracic walls are 
driven inwards by the pressure of the atmosphere upon their outer sur- 
face. In a case that we saw ourselves in a child fourteen months old, who 
had presented symptoms of atelectasis from birth, and in whom we found 
after death very extensive collapse, this symptom was very marked. The 
base of the thorax was indented on both sides by a deep gutter or depres- 
sion, which remained depressed and unchanged during the ins{)iratory 
movements, or which, indeed, rather became more distinctly visible during 
those motions, .so that the chest presented the curious spectacle of dilata- 
tion or expansion in its upper parts, during inhalation, and of contraction 
or collapse at its ba.se. 

In regard to this interesting sign the reader is referred to our article on 
rickets, where is mentioned the explanation given of It bv Jcinur, In c<m- 
DectioD with the latter disease. 

Symptoms of CV)li.apse in the Early Wi.i.k- of J^iie. — J>«iorc 
taking up the regular consideration of p)st-natal collapse, aa it occurs at 
all agG<« of childhood, we wish to refer, for a moment, to that condition aj» 
it appears in the first few weeks of life, in infants who have exhibited no 



134 ATELECTASIS PULMONUM. 

sign of it whatever, perhaps, at the moment of birth. We desire to do 
this now, because the symptoms to which it gives rise resemble much more 
those of congenital atelectasis, than those of collapse in children over a few 
months old. And let it be remarked that these symptoms are very differ- 
ent, and much more severe and threatening than those of collapse at later 
periods. They are in fact those of cyanosis, and, in some instances, are as 
strongly marked as those observed in the worst cases of that condition, 
caused by malformation of the heart or great vessels. The cyanosis and 
other symptoms of disordered circulation evidently depend on the obstacle 
offered by the collapsed and condensed portions of lung-tissue to the dis- 
charge of blood from the right side of the heart. Though this obstacle to 
the venous circulation is doubtless the chief cause of the symptoms in 
these cases, we cannot but think ourselves, that the great difference be- 
tween the symptoms of congenital atelectasis, as well as of post-natal ate- 
lectasis occurring in the first few weeks of life, and the collapse of later 
periods, must be explained in part, at least, by the fact that the foetal 
openings, the foramen ovale, and ductus arteriosus, and especially the 
former, are still patulous, or in such a condition that they may be re- 
opened under pressure, and so allow a portion of the contents of the 
overloaded and congested right side of the heart to pass into the left auri- 
cle, thence into the left ventricle and aorta, and so to the whole body. 

In this form of atelectasis, the child may have been born perfectly 
healthy, or only weaker than usual, or it may have had some difficulty in 
establishing the respiration, which, however, has afterwards been effected 
in the most complete manner. Some days, or even weeks after birth, 
from a cause disturbing the function of respiration, portions of the lung 
may collapse, and give rise to the different symptoms of that condition in 
the manner above described. The most important of these symptoms are 
difiiculty of breathing, consisting either in an increased or diminished rate 
of that function, diminution of the muscular power, cyanotic hue of the 
skin, and slight or severe spasmodic phenomena. In a case that occurred 
to one of ourselves (see Am. Journ. Med. Sc, loc. cit.), a child who had ex- 
hibited at birth, and for five days after, every appearance of fine health, 
was observed on the sixth day to cry rather violently in the morning. At 
one o'clock in the day he began to moan, and appeared distressed ; at two 
he ceased to moan, became bluish, and seemed to lose his breath. He 
was placed in a bath, in which the blueness passed off, but the breath- 
ing continued irregular and uneven. He soon became blue again, and 
breathed slowly and irregularly, but had no spasm. At about four o'clock 
another paroxysm occurred, in which the whole surface became first blu- 
ish, and then dark, while at the same time, the trunk and limbs became 
stiff and rigid under the influence of tonic muscular spasm, and the res- 
piration was slow and imperfect. After the attack had lasted for some 
moments, the blueness and spasmodic phenomena disappeared, but the 
child remained in a state of stupefaction. There were two slight parox- 
ysms of convulsive stiffening between this and evening, and later in the 
evening there was still some blueness, with irregular and short respiration. 
During the night the breathing was short and uneven, and attended with 



SYMPTOMS. 135 

moaniug, but on the following day the symptoms had disappeared entirely, 
and there was no return. 

In another case the symptoms of collapse did not appear until the 
twenty-tifth day after birth. The infi\ut had been hearty and strong at 
birth, and had established its respiration fully and completely. Between 
the birth, however, and the time of the attack, circumstances connected 
with the lactation had caused the development of diarrhcra with thrush, 
which had debilitated the child a good deal. On the day of the attack, 
frequent sneezing, with stuffing of the head, and some cough, seenied to 
show the existence of catarrh, and on the same day, the child was unfor- 
tunately exposed, owing to the accidental opening of one of the gas- 
burners, to the inhalation of some gas. Late in the evening, a slight 
whistling or stridulous sound was heard in the breathing, the skin became 
suddenly a little bluish, and a slight convulsion followed. During the 
night there were frequent and strong convulsive seizures, always preceded 
and followed by deep blueness of the mouth, hands and feet, and it was 
noticed that the least disturbance, as lifting or nursing, or changing the 
position, always brought them on. The next morning the attacks con- 
tinued, but with diminished violence, under the effects of treatment, and 
they ceased after the middle of the day. The color of the skin had now 
changed ; it had become rosy red, instead of pale or blue, and the hands 
and feet, which had been cold, were now warm and natural. There was 
DO return after this. 

In a third case, a female infant, who had been perfectly well at birth 
and up to the moment of this attack, was put suddenly into a bath by 
the nurse on the eighth day, directly after its waking from sleep. The 
child, who was not thoroughly waked up, seemed greatly terrified, and 
began to scream most violently. Instead of removing the infant from 
the water, the nurse persisted in holding it immersed for some minutes, 
when it became deeply blue, and partially convulsed ; it frothed at the 
mouth and nose, seemed to be suffocating for breath, and appeared to be 
dying. These symptoms continued for three-quarters of an hour, when 
they gradually passed away, and it fell into a heavy sleep. When we 
saw the infant, soon after this, the only signs of disorder that remained, 
consisted of an unusual paleness, drowsiness, and an expression of feeble- 
Dess. Some three hours later, it waked, nursed, and from that time seemed 
quite well. 

In a fourth case, a child bom apparently well, with the exception of 
its having had a rather frequent respiration, and who nursed very well 
on the second and third day, was attacked on the fourth day with blue- 
ness, moaning, short and panting respiration, and then with slight con- 
vulsive symptoms. It was unable to nurse, and though kept perfectly 
Btill, and fed from time to time with small quantities uf milk and brandy, 
became gradually more dee|)ly blue, had paroxysms of very slow res- 
piration and circulation, with general convulsive seizures, and died at the 
end of twenty-four hours. 

The reader will alsf) find this form of cyanosis referred to in our article 
on that disease. 



136 ATELECTASIS PULMONUM. 

Diagnosis. — There can be no difficulty in detecting the nature of the 
case when the imperfect expansion exists from birth, and when the physi- 
cian is present at that event. 

When, however, collapse of the lung-tissue continues after birth, and the 
physician is called upon to determine, at the age of some days, weeks, or 
even months, the cause of the feeble health and puny growth of the child, 
or to explain those sudden attacks of collapse in very young infants who 
had previously well established, to all appearances, the respiration, the 
diagnosis becomes more difficult. In the former class of cases, attention 
to the following points will usually, however, enable us to make a correct 
diagnosis. The previous history is particularly important, since, in all such 
cases, it will be found that the infant was either still-born and resuscitated 
with more or less difficulty, or that it was born weak and feeble, and that 
the respiration had not been established as thoroughly and completely as 
it ouglit to have been. Dr. Rees states that certainly half of the cases of 
this form, in his own practice, occurred in twins, and that they were all 
born in a more or less completely asphyxiated condition. The present 
symptoms are also very important. The feeble appearance of the child, 
and its puny growth, in connection with its past history, and the absence, 
as ascertained by careful examination of the case, of other morbid condi- 
tions to explain the general ill-health, ought to direct the attention of the 
physician to the true nature of the disease ; and if we add to these con- 
siderations the local thoracic symptoms, the short, rapid and imperfect 
breathing, with, perhaps, the altered movement of the ribs, the indentation 
instead of expansion during inspiration, mentioned above ; the absence of 
fever; and the existence of the physical signs of more or less extensive 
solidification of the pulmonary tissue, without those of pneumonia; there 
will seldom be any difficulty in forming a correct diagnosis. 

The cases described under the head of collapse in the early weeks of life 
may be readily understood from the simple fact that the symptoms can- 
not be satisfactorily explained by referring- them to any other condition 
than that of collapse of portions of the lung, with impeded and deranged 
circulation. 

Prognosis. — The condition of imperfect expansion of the lungs in a 
new-born child, does not necessarily cause it to die immediately or very 
soon after birth. The fate of the child will depend very much upon the 
cause of the atelectasis, upon its degree of innate strength and vigor, and 
upon the kind of hygienic conditions to which it may be consigned. When 
the child is well developed, and not enfeebled by any fault in the mother's 
health during the pregnancy, but merely by some momentary condition 
that has occurred during the labor, there is every reason to hope that 
proper hygienic and medical treatment may restore it to health. The 
danger is greatest in those who continue weak and feeble, in spite of the 
proper measures of care and treatment, for some days or weeks after birth. 
We have a record of ten examples of this condition in new-born children, 
in nine of which the symptoms persisted during a period varying between 
six hours and five days. Of these, seven lived, while three died in from 
twenty-one hours to three days. 



TREATMENT. 137 

The prognosis of the second class of cases — those in which collapse oc- 
curs suddenly a few days or weeks after birth, and after the apparently 
complete establisliment of respiration — will vary, of coui*se, with the vio- 
lence of the symptoms. Of five cases of this kind that came under our 
observation, recovery took place in three in spite of the most dangerous 
and alarming symptoms, while in two death occurred in a period of about 
twenty-four hours. 

In cases where the collapse of the lungs has been extensive, and has in 
part persisted without proving fatal, serious organic changes in the heart 
have been found to follow, both by F. Weber and Steffen. The long-con- 
tinued obstruction to the pulmonary circulation prevents the closure of the 
ductus arteriosus, and subsequently causes hypertrophy with dilatation of 
the right side of the heart, a patulous state of the foramen ovale, and at 
last eccentric hypertrophy of the left auricle and ventricle. Undoubtedly, 
in most case;?, death occurs before these changes in the heart are induced, 
but it is important to be aware that imperfect expansion of the lungs may 
thus serve to develop serious cardiac disease of a form likely to be attended 
with cyanosis. 

When the imperfect expansion depends upon the presence of accumula- 
tions of mucus in the air-passages, well-directed efforts usually succeed in 
effecting the removal of the obstruction, and the establishment of free in- 
spiration. In those cases, finally, where there is pressure upon the pneumo- 
ga^tric nerves near their origin, a fatal result must always follow. 

Treatment. — The treatment of congenital atelectasis must be directed 
to the removal of its probable cause. If this is suspected to be obstruction 
of the air-passages by collections of mucus, the infant's mouth should be 
cleansed, and vomiting provoked by tickling the fauces. In addition to 
this, all the measures calculated to stimulate respiration should be employed. 

When the imperfect expansion appears to depend merely on the weak- 
ness of the infant, the treatment resolves itself almost entirely into the em- 
ployment of such means as tend to invigorate the general health of the 
child, and to promote the activity of the respiratory act. In a recent case, 
one dating from birth, in which the function has always been imperfect, 
and in which there are present great feebleness, drowsiness, and paleness 
or blueness, the room in which the infant is placed should be kept up to a 
temperature of 70^ or 75^, and the child should be abundantly covered 
with warm clothing. Perfect quiet, or at least very gentle motion, is very 
important, and when there is any disposition to deep blueness or to convul- 
sive movements, attention to this point is essential. It \s in such cases, 
and in those in which these symptoms come on a few days or weeks after 
birth, that the position recommended by the late Dr. C. D. Meigs, for the 
treatment of cyanosis neonatorum, wjis found by him so useful. This j)osi- 
tion is one upon the right side, with the head and shoulders raised at an 
angle of 45°. It is obtained by arranging pillows in such a way as to form 
a plane inclined at that angle. Up<^)n this the infant is placed, and orders 
are given that it is not to be moved at all, if possible, or only with the 
greatest care and gentleness, for twenty-four or forty-eight hours. There 
can be no doubt that this position and the attendant repose have, in many 



138 ATELECTASIS PULMONUM. 

cases recorded by Dr. C. D. Meigs, and in several that we have seen our- 
selves, been of very great use in controlling the symptoms. Its good effects 
in cyanosis were supposed by him to depend on the fact that the septum 
auricularum becomes horizontal in this position of the body, so that the 
blood in the right auricle must rise against gravity, in order to pass 
through the foramen ovale, while, at the same time, the valve of that 
opening is disposed to fall down by its own weight, and close the foramen, 
and is, moreover, pressed downwards by any blood that may enter the left 
auricle from the pulmonary veins. This explanation will apply, of course, 
only to those cases of atelectasis accompanied by very extensive and deep 
blueness or purple color of the surface, in which we may suppose that so 
much of the pulmonary tissue is solidified, as to produce a degree of ob- 
struction to the passage of blood from the right side of the heart into the 
lungs, sufficient to overload the right ventricle and auricle, until the latter 
pours a portion of its contents into the left auricle, thus causing admixture 
of the two kinds of blood. In a large majority of the cases of atelectasis, 
however, this explanation of the benefit resulting from the treatment re- 
ferred to, cannot be received, as there is no reason to suppose that in them 
the slight cyanotic symptoms present indicate anything more than the ex- 
istence of a moderate degree of congestion of the right side of the heart, 
unattended by any escape of blood from the right into the left auricle. In 
such cases the position on the right side is useful, because it is the one most 
favorable to a full and easy performance of the respiratory and circulatory 
functions. It leaves the left side free and unembarrassed, so that the heart 
can act with the greatest possible freedom, while the partial elevation of 
the head and shoulders renders the movements of the chest more easy and 
complete than when the body is lying on a horizontal surface. The perfect 
quiescence which constitutes a part of the treatment is also very important, 
as in many recent and particularly in cyanotic cases, the symptoms are 
greatly aggravated, and convulsive attacks often brought on by moving the 
child, especially if this be done suddenly or rudely. 

Various means are also recommended for rousing the force of respira- 
tion, as by compelling the infant to cry, by frictions of the surface, by 
plunging the body alternately into warm and cool water, or by allowing a 
stream of cold water to fall on the nape of the neck with the view of ex- 
citing the respiratory nerve-centres. 

Attempts may also be made to produce full inflation by gentle mouth- 
to-mouth respiration. The other modes of attempting to accomplish this 
are either (as by compressing the thorax at regular intervals) of but little 
value, or (as in case of Hiiter's proposal to inflate the lungs after catheter- 
ization of the larynx) highly objectionable. 

Perhaps the most important point of all in the treatment of this affec- 
tion, especially when the symptoms tend to become persistent, is the mode 
of nutrition of the child. If possible, the infant should always have a good 
breast of milk, and if unable to suck, the milk ought to be drawn by means 
of a breast-pump, and given to the child in small quantities from a spoon. 
About two or three teaspooufuls may be given at first every half hour or 
hour, and the quantity gradually increased until the child gains strength 



COLLAPSE OF THE LUNG. 139 

enough to be put to the breast. If breast-milk canuot be procured, cow'3 
milk and water may be substituted, in the proportion of one part of the 
former to two or three of the latter. The only medicines to be given are, 
at first, while the child is still very young and weak, mild stimulants, of 
which the best, in our opinion, is fine old brandy. Of this about five drops 
may be given each time that the milk is taken ; or, we may make use of 
from three to five drop doses of the aromatic spirit of hartshorn, or of 
proper quantities of wine-whey. 

When the symptoms of congenital atelectasis tend to persist for several 
weeks or months, or when we first see the patient some time after birth, 
the chief points to be attended to in the treatment are, as before, the mode 
of nutrition, which ought to be by nursing and the use of gentle stimulants 
and tonics. Brandy, wine, or Huxham's tincture of bark, are the best 
stimulants ; whilst quinine, in the dose of a quarter or half a grain, three 
times a day ; extract of cinchona, in the dose of from one to three or four 
grains, three times a day ; or iron in the form of Quevenne's powder, or in 
that of the iodide, are the best tonics. 

Vogel (Dis. of Children^ Amer. ed., 1870, p. 55) speaks very highly of 
the advantage derived from the cautious application of electricity to the 
pectoral muscles. 

COLLAPSE OF THE LUNG, OR POST->'ATAL ATELECTASIS. 

General Remarks. — By collapse of the lung is meant the return of 
that organ to its fcetal or unexpanded state. It is in fact a condition of 
atelectasis or imperfect expansion of its vesicular structure. The terms 
collapse or post-natal atelectasis are employed to contradistinguish it from 
congenital atelectasis, the former being applied to imperfect expansion as 
it occurs in lung-tissue after previous expansion, and the latter, as stated 
in the preceding article, to the same condition as it exists in children who 
have never expanded certain portions of the pulmonary substance. 

The true nature of collapse of the lung was never understood, and its 
great practical importance never appreciated, until since the year 1844, 
when MM. Legendre and Bailly published, in the Archives Gauraks de 
3ftd€cine, their researches on the subject. Since then various observers 
have repeated the investigations of those gentlemen, and thrown new light 
upon the matter. Among the most important of the later writers on this 
subject, we may mention Dr. Charles AVest of London, MM. Hardy and 
Behier of Paris, Dr. W. T. Gairdner of Edinburgh, and MM. Till lie t and 
Barthez, in the second edition of their work. 

This discovery in pathology was one of very great value, not morcly be- 
cau.se it renders our knowledge of the morbid conditions of the lungs 
more exact and philosophical than it ever was previously, but because it 
explains certain anatomical changes in the pulmonary structures, often 
before noticed and described, but never satisfactorily accounted for; and 
still more, because it points to methods of treatment much more rational 
and much more successful than those employe<J under the influence of 
former ideas as to the nature of the lesions alluded to. The most im- 



140 COLLAPSE OF THE LUNG. 

portant result of the new views is the disclosure of the fact that several 
lesions met with after death, which were formerly thought to depend on 
inflammation of the affected tissue, are in reality the consequences of col- 
lapse or obliteration of the vesicular structure of the lung, and not of 
inflammation, as was at one time supposed. The lesions alluded to are 
those which have been hitherto described under the names of lobular 
pneumonia and carnification. 

The peculiar character of the lesions met with in many of the supposed 
cases of pneumonia, had often attracted attention and been commented 
upon, before their real nature came to be understood. The points of dif- 
ference between these alterations and those of true pneumonia were par- 
ticularly noticed by MM. Denis, De La Berge, Rufz, Eilliet and Barthez, 
Dr. Gerhard, and Dr. West. In fact, M. Rufz, and MM. Rilliet and 
Barthez, both approached very near the truth in regard to these lesions, 
each comparing them, but the former at an earlier period than the latter, 
to the condition of the lung of a foetus that has never breathed. The 
latter writers, in the article on pneumonia in their first edition, have de- 
scribed a condition of the lung which differed so much from ordinary 
pneumonia as to create a great difficulty in their minds as to its true na- 
ture, and to it they applied the term carnification. They were on the 
very verge of detecting its real character; they did in fact suggest its 
real character, but were so possessed with the idea that it must be the 
result of some inflammatory action as to neglect to pursue their own sug- 
gestion, but endeavored to explain the condition on the ground that it was 
"one mode of termination of pneumonia, or else chronic pneumonia." 
The following passage, quoted from their work (lere ed., t. i, p. 74), will 
show how closely they approached the truth : " The first idea that enters 
the mind on examining this tissue (carnification) is, that it resembles the 
lung of a foetus that has not breathed ; we should feel inclined to say that 
the pulmonary vesicles had not yet been dilated under the influence of the 
thoracic expansion, and had not, therefore, admitted air into their interior; 
or, rather, it would seem as though they had been obliterated by some 
attack of disease, perhaps inflammation, without, however, remaining en- 
gorged, and after having lost the power of dilatation." 

In the second edition of their great work, MM. Rilliet and Barthez 
adopt, in great measure, the views of MM. Legendre and Bailly, and of 
Dr. Gairdner, not only in regard to carnification, but also in regard to 
the yet more important lesion hitherto generally called lobular pneu- 
monia. 

But it is not only the condition of the lung called carnification that 
has been shown to consist, not in inflammation, but in a collapse of the 
pulmonary tissue. A much more important consequence of the recent re- 
searches has been the discovery that in a very large majority of cases the 
so-called lobular pneumonia, generalized lobular pneumonia, and pseudo- 
lobar pneumonia of different writers, are also the results of collapse of the 
lung, variously combined with bronchitic inflammation and congestion of 
the pulmonary tissue. The latter discovery has lessened very much the 
importance of pneumonia as a disease of early life, while it has augmented 



ANATOMICAL LESIONS. l-il 

in the same proportion that of bronchitis, for it has shown that a very large 
number of cases, formerly regarded as true iuflamnuition of the parenchyma 
of the lung, are in fiict cases of bronchitis combined with collapse of the 
tissue of the organ. 

Now that the nature of collapse of the lung, in connection with bron- 
chitis, and sometimes, also, with true pneumonic inflammation or conges- 
tion, has been made known, a number of symptoms occurring in the pul- 
monary atlections of children, which formerly seemed obscure and irregular, 
have become easily explicable. It had been often observed that many of 
the supposod pneumonias of children did not present the same symptoms, 
pui"sue the same course, nor require the same treatment as the pneumonia 
of adults, or as some cases of the disease in children. In a great many of 
the supposed cases there was an unusually large amount of bronchial in- 
flammation, the general symptoms were much less acute than was to be 
expected in a parenchymatous inflammation, and what was most singular 
of all, the physical signs of solidification of the lungs were very variable 
and uncertain, there being present on one day the signs of simple bron- 
chitis, while on the same day or the following, and over the same region of 
the thorax, these would be associated with or masked by the signs of indu- 
ration of the lung; and again, in a day or two, the symptoms indicative of 
condensation might disappear, to be succeeded yet again by those of simple 
bronchial inflammation. The effects of treatment seemed also to point 
clearly to a radical difference between the lobular or broncho-pneumonia 
of children, and the acute phlegmasial disease of adults. It was found, in 
fact, that depletory measures were seldom borne well in the lobular pneu- 
monia of children, while in the pneumonia of the adult, and in some 
acute cases occurring in early life, which presented the same general 
symptoms and the same physical signs as pneumonia in the adult, anti- 
phlogistics, as is well known, are amongst the most successful remedies 
that can be made use of 

Anatomical Lesions. — Collapse of the lung (post-natal ) occurs in two 
different forms, the diffused, and the limited or lobular. The only difference 
between the two forms is in the number of lobules aflTected, and their mode 
of distribution. In the diff'used variety, a large number of adjoining lobules 
collapse, and give a condensed and solid appearance to larger or smaller 
portions of the lung, most frequently to the edges merely of one of the 
lobes, but at others to the greater part or the whole of a lobe, or even the 
major part of a lung. In the lobular variety, on the contrary, single 
lobules or clusters of lobules become collapsed in different parts of a lobe 
or lung, and the affected portions take the form of irregular hardened 
patches or tumors, situated upon the surface, or disseminated through the 
interior of the pulmonary texture. In the former kind of collapse, the 
appearance of the altered portion of the lung is somewhat that of loi)ar 
pneumonia, and it is to these cases that the terms generalized lobular, 
pseudo lobar, carnification, and splenization, have been applied ; while in 
the latter kind, the isolated and distinct condensed f>ortions have been de- 
scribes! by the term lobular pneumonia. 

The peculiar or fundamental characters of collapsed pulmonary tissue 



142 COLLAPSE OF THE LUNG. 

are the same in both varieties. We will mention them as succinctly as 
possible, and then compare them with those of pneumonia, for the reason 
that it is with the lesions of that disease that those of collapse have been 
so frequently confounded. 

Collapsed lung is generally of a dark violet color, but it may be much 
darker in tint, and even black, when it is much engorged with blood. Its 
consistence is always changed ; the condensation may amount merely to 
slight hardening, with a diminution of the crepitation, or it may be very 
dense with an entire absence of crepitation, in which case portions thrown 
into water sink rapidly. Though more or less hardened, the tissue still 
retains a certain degree of flaccidity and suppleness. When cut into, the 
surface is seen to be smooth and uniform, having somewhat the appear- 
ance of muscle, and presenting no granulations. Pressure or scraping 
causes the exudation of more or less semi-transparent bloody serosity. 
Close examination shows that the organic elements of the tissue, the ves- 
sels, bronchia, cellular tissue, etc., can still be distinctly traced. Lastly, 
inflation of the lung distends the condensed parts, and gives to them 
again, more or less completely, their natural physiological characters. 

MM. Rilliet and Barthez, in their second edition, treat, at considerable 
length, of congestion of the lung as a very constant accompaniment, and 
as a very important element in the state of collapse. They regard this 
congestion as being connected nearly always with bronchitic inflamma- 
tion, and as being not merely a passive state, but as exhibiting phenom- 
ena, in most instances, which prove it to be in some degree an active con- 
dition. They say (op. cit, t. i, p. 428) : " We readily acknowledge that 
a state of debility, prolonged dorsal decubitus, and the obstruction to the 
circulation thus occasioned, facilitate the production of this condition, 
and give to it the appearance of a simple passive congestion. But we 
believe that there exists, moreover (frequently, if not always), a really 
active and even inflammatory movement." They regard this opinion as 
proved chiefly by the fact that they have found the texture of the affected 
parts to be somewhat softened, as shown by the facility with which they 
are torn by the finger or by scraping with a scalpel ; by the swelled and 
turgid condition the tissues exhibit ; by the quantity of sanguineous or 
sero-sanguineous liquid which escapes on pressure ; and by the presence of 
a serous exudation around the pulmonary vesicles, while the interior of the 
vesicles appears to be healthy. The last-mentioned condition they found 
upon their own observation, and upon a microscopic examination made by 
M. Lebert. 

The color is different in the two alterations ; being, in collapse, purple 
or livid, and, in pneumonia, brownish-red or fallow-red. In pneumonia 
the pleura covering the hepatized portions is often covered with false 
membrane, showing thereby the inflammatory nature of the disease ; in 
collapse this is rarely the case, and only when there is some accidental 
concomitant pneumonia. The density of the lung in the two conditions 
is of a different kind : in pneumonia it is hard to the touch, and unyield- 
ing ; in collapse it always retains a certain degree of flaccidity and soft- 
ness, like that of muscular tissue. In pneumonia the diseased part is 



ANATOMICAL LESIONS. 143 

turgid and swelled, so that it projects above the common level of the sur- 
rounding surface; in collapse, on the contrary, it is shrunken and de- 
pressed below the neighboring parts. lu pneumonia the ettect of the in- 
flammatory process on the tissues is very strongly marked, and produces 
changes in them very different from those occasioned by mere collapse. 
In the former disease the cohesive properties of the pulmonary structure 
are very much lessened, so that the inflamed parts are readily penetrated 
by the finger, and are easily torn ; in simple collapse, on the contrary, 
the diseased part is as firm and resisting, or even more so, than in health ; 
whilst in collapse occurring in bronchitis and attended with congestion, 
though the cohesion of the tissues is somewhat lessened, it is never nearly 
so much so as in pneumonia. In the true hepatization of pneumonia, a 
cut surface always presents a granular aspect, while in collapse, on the 
contrary, it is smooth and even. On scraping a cut surface it is found 
that, in the former alteration, a plastic, fibrinous matter, of a yellowish, 
orange, or gray color, comes off on the knife; while, in collapse, only 
some semi-transparent bloody serosity is scraped off. In the former, the 
anatomical arrangement of the lobules cannot be seen, as the inflamma- 
tion attacks iudiflerently the lobules themselves, the interlobular septa, 
and parts of neighboring lobules; but, in the latter, the alteration can 
always be seen to be more or less regularly confined to the lobules, the 
cellular interstices between the lobules remaining more or less apparent; 
so that in pneumonia the alteration is not bounded at all by the outlines 
of the lobules, while in collapse the alteration always affects, more or less, 
the lobular form. To conclude, the effects of inflation are altogether dif- 
ferent in the two conditions. M. Legendre (Recherches Anatom.-Pafh. et 
Clin, stir quelque.i Mai de V Enfance, p. 164) states that air can never be 
made to penetrate by inflation into a completely hepatized lung. Neither 
in hepatization of the lobar form, nor in true partial hepatization, has he 
ever been able, even with the utmost effort, to push air into the inflamed 
tissues. After repeated trials, the tissue remained compact and friable, 
and sank as rapidly as before when thrown into water. In the foetal state, 
on the contrary, the slightest effort sufl[iced to fill and distend the collapsed 
air-cells, and to give to the altered portion its natural appearance, except- 
ing that it became more red in consequence of the oxygenation of blood 
contained in the capillaries. Dr. Gairdner (Pathol. Anat. of Bronchitis, 
etc., Edinburgh, 1850, pp. 13, 14) remarks that, though this test " is very 
useful in demonstrating the nature of the lesion, in a favorable case, to 
one not familiar with its character, I do not believe it to be applicable to 
the determination of the presence or absence of pneumonia in those mixed 
cases in which alone there is any difficulty." He has observed, in fact, 
that partially pneumonic lung may be inflated when the affortion is rerent 
and combined, as it frequently is, with bronrhitic collapse, while in the 
latter lesion, in its purest forms, cr>mplete inflation is often very difficult 
or impossible after the collapsed state has been of .some duration. 

The part of the lung in which collapse is mcjst frequently met with de- 
pends somewhat on the form of the alteration. In the diffused vari»'ty, 
it may affect a more or less considerable portion of either or both lungs, 



144 COLLAPSE OF THE LUNG. 

but is most commoD at their posterior part. The lobular variety is most 
common ou the anterior edges, but may, like the diffused, occur in any 
other part. As a general rule, the alteration is most frequent at the pe- 
riphery of the organ, where its edges are thin, as along the margins of the 
lobes, in the languette of the upper lobes, and at the bases of both lungs. 
The parts just named are those most distant from the primary air-passages ; 
they are those in which the inspired air would arrive last, and with the 
least force of impulsion. 

Causes. — It has been generally acknowledged that there are two prin- 
cipal causes by which to explain the production of collapse of the lung. 
These are the presence in the bronchia of some condition which acts as an 
impediment to the ready passage of the inspired air, and a want of power 
in the muscular apparatus by which the function of respiration is carried 
on. To these Dr. Gairdner adds another, — the inability to cough and 
expectorate, and thus remove the obstructing mucus ; but this is, in fact, 
included in the preceding. 

The most important of the above-mentioned causes is evidently the de- 
ficient respiratory power, since this is noticed and insisted upon by all ob- 
servers. It has been found, in fact, that collapse seldom occurs to any 
considerable extent except in children who are exhausted and debilitated. 
The debility may be congenital, it may be the result of wearing diseases, 
as diarrhoea, hooping-cough, measles, typhoid fever, etc., or it may depend 
on exposure to unwholesome and enfeebling hygienic conditions. It is 
easy to understand that a child who is either born weak and feeble, or who 
becomes so in after years from any of the causes just alluded to, must lose, 
■with the general decay of the strength of the body, some portion of the 
muscular power by which alone a complete and efficient dilatation of the 
thoracic cavity can be accomplished, and that, when this is the case, the 
inspirations must be short and imperfect, and that portions of the lung 
most distant from the primary air-passages, not being reached by the in- 
spired air, will I'emain in an unexpanded or collapsed state. If we add 
to this state of feeble respiratory power, the presence of opposing secretions 
in the air-tubes, whether these be the consequence of bronchial inflamma- 
tion, as they are in the immense majority of cases, or, as Dr. Gairdner 
suggests they may sometimes be, the mere natural secretion of these tubes, 
accumulated for the want of power to throw them off, it becomes abun- 
dantly easy to comprehend the mode of production of collapse, in at least 
some of the examples. 

Whether a simple deficiency of inspiratory force alone, without obstruct- 
ing mucus in the bronchia, W'ill give rise to collapse, is a somewhat mooted 
point. Dr. West agrees with MM. Legendre and Bailly, in the opinion 
that it is often due to the inspiratory power having been inadequate to 
overcome that natural elasticity of the lung which opposes a full dilatation 
of the organ. Dr. Gairdner {loc. cit, p. 33) cannot "see reason to believe 
with Dr. West, that mere debility, apart from any obstruction in the tubes, 
is a sufficient cause for collapse in the child." He remarks, and with strong 
show of reason, that the very fact of the lesion being usually more or less 
lobular, or partial in its distribution, appears to indicate special circum- 



CAUSES. 145 

stances of a local kiud, as having a marked influence on the production of 
this affection. What is of most consequence, however, to the working 
physician, as an important practical truth, is the fact stated by several 
observers, and adverted to by Dr. Gairduer himself, that in some cases no 
signs whatever of obstructive bronchitis or of bronchial accumulation can 
be discovered during life. Before leaving this point, we desire to call 
attention to the opinion of Hasse {Pathol. A)iat., Syd. Soc. ed., p. 253), 
that, though this partial introduction of air might be deemed at variance 
with the laws of respiration, inasmuch as the atmospheric pressure must 
necessarily distend the entire lung equally, not to the exclusion of a lobe, 
and still less to that of a lobule, the objection falls to the ground when it 
is considered that the o|>eration of these laws is the result of previous 
muscular action. He refers to the fact that in pleurisy one-half of the 
thorax, and in partial pleurisy certain portions of that cavity, do not share 
at all in the movements of the remainder. " "We need, therefore," he says, 
"be at no loss to understand how defective breathing may originate in a 
merely partial activity of the intercostal or other respiratory muscles." 

Dr. Gairdner, as already stated, considers as one of the causes of col- 
lapse, an inability to cough and expectorate, and thus to remove the ob- 
structing mucus. The views which he expresses on this point are very 
interesting, and also, we think, very important. He states that Laeunec 
supposed the expiratory force of respiration to be weaker than the inspi- 
ratory, while in fact the experiments of Hutchinson and Mendelsohn, to 
which he refers, prove that though ordinary inspiration is more of a mus- 
cular act than ordinary expiration, yet the residual effective force for over- 
coming adventitious obstruction is very considerably greater in expiration. 
" The forced or muscular expiratory act is, in fact, about one-third more 
powerful, as measured by its effect upon a pressure-gauge, than the extreme 
force of inspiration ; and it is this force which is thrown into action when 
obstruction in the tubes is to be overcome." In the act of coughing, the 
air in the vesicles is brought to bear upon the obstructing substance within 
the bronchia, at a maximum amount of outward pressure, and with the 
additional mechanical advantage of a sudden impulse, so that the practical 
efficiency of the expiration in forcing air through obstructions must be far 
greater than that of inspiration. It is clear, therefore, that if the secre- 
tions in the air-passages be so abundant or so viscid as to interfere materi- 
ally with the entrance and exit of air, they must necessarily occasion col- 
lapse, either partial or total, of the parts beyond them, since not only does 
the air enter with difficulty, but being expelled with greater force and in 
larger quantity than it can be drawn in, the amount remaining in the vesic- 
ular structure must gradually dirainij^h. This effect of obstruction will be 
still more remarkable when the muscular force of respiration is diminished 
by debility of the patient, for then the inability of the inspiratory act to 
replace the air driven out by expiration, will be yet more marked than 
when the muscular powers of the body retain their full force. 

There is still another mechanical condition which tends to produce col- 
lapse from obstruction, to which Dr. Gairdner refers. This condition is to 

10 



146 COLLAPSE OF THE LUNG. 

be found in the form of the bronchial tubes. These tubes are a series of 
gradually diminishing cylinders, and if a plug of any kind, but especially 
one closely adapted to the shape of the cylinders, and possessing consider- 
able tenacity, be lodged in any portion of such a cylinder, it will move 
with much more difficulty towards the smaller end, and in doing so will 
close up the tapering tube much more tightly against the passage of air, 
than when moved in the opposite direction into a wider space. From this 
arrangement of the parts, it will happen that at every expiration a portion 
of air will be expelled, which, in inspiration, is not restored, owing in part 
to the comparative weakness of the inspiratory force, and in part to the 
valvular action of the plug. "If cough supervene, the plug may be en- 
tirely dislodged from its position, or expectorated, the air, of course, re- 
turning freely into the obstructed part ; but if the expiratory force is only 
sufficient slightly to displace the plug, so as to allow of the outward pas- 
sage of air, the inspiration will again bring it back to its former position, 
and the repetition of this process must, after a time, end in pefect collapse 
of the portion of lung usually fed with air by the obstructed bronchus." 

We have been thus particular in our consideration of the causes of col- 
lapse, because we are convinced, from personal observation, that it is a 
subject of very great importance in practice. Many times, in the last few 
years, we have met with cases of bronchitis, either primary or secondary, 
in weak and debilitated children, in which the general and local symptoms 
have pointed clearly to the existence of collapse of the lung, and in which, 
moreover, the good effects of a sustaining and even stimulating treatment 
have shown the great utility of an acquaintance with the nature of this 
affection, and its proper remedies. 

Symptoms. — As collapse of the lung occurs almost always in connection 
with bronchitis, though sometimes, also, after, or concomitantly with pneu- 
monia, it is clear that the symptoms which reveal its existence must be 
mingled, in a greater or less degree, with those of the two diseases just 
named. It is true, nevertheless, that it sometimes occurs unassociated with 
more than very slight evidences of any other disease of the lung. Cases 
of the latter kind have been usually observed only in children dying in 
states of utter exhaustion, in whom the muscular power of respiration has 
been so greatly weakened, as to prevent a dilatation of the thoracic cavity 
sufficient to carry air into the deeper parts of the lung. In such instances, 
the symptoms of collapse do not show themselves until a very short time 
before death, and they consist in the sudden appearance of very rapid and 
oppressed breathing, with little or no cough, in more or less extensive dul- 
ness on percussion over different parts of the chest, but most frequently 
the inferior dorsal regions, and in feeble or suppressed respiratory murmur, 
or more frequently a distant and imperfect bronchial respiration. In some 
cases, however, in which there is very little bronchial complication, as 
shown by the rarity and small amount of the catarrhal rales, the symptoms 
of collapse continue with more or less irregularity, as to situation and ex- 
tent, for periods of several weeks, or even months. But here, also, as in 
the cases previously referred to, the general debility and low health of the 
child are strongly marked, and are, with slight variations persistent. * As 



ILLUSTRATIVE CASE. 147 

an instance of this kind of collapse, we may cite the following case, which 
occurred in the practice of one of ourselves : 

A boy, between throe and four months old, who, at birth, and up to the time of 
this attack, had presented every appearance of strong and vigorous health, was 
seized, on the 3d of October, 1840, with symptoms of a somewhat irregular and 
anomalous character, but which we soon suspected te be the signs of an intermit- 
tent fever. "We were induced in part to make this diagnosis, from the fact of having 
attended the mother during her gestation of this child, in a severe attack of inter- 
mittent fever. At the beginning of the sickness, there was some little coryza, but 
no cough whatever. On the 3d of October, after the coryza had lasted for a few 
days, he became worse, and wc were sent for. During the six days following this, 
he had one or two attacks each day of coldness of the extremities, followed by vio- 
lent fever, and ending sometimes with perspiration. He was exceedingly fretful, 
screamed a great deal, was at times drowsj^ and dull, and vomited occasionally. 
The stools were regular and perfectly' natural. The breathing was rapid and short 
nearly all the time, but there was no cough whatever. On the seventh day, the 
respiration was 100 by the watch, and irregular. The child was pale, weak, drowsy, 
and entirely without cough. Percussion revealed nothing, and no. rales could be 
beard. On the eighth day, the breathing was 9G, and a slight, dry cough was 
heard two or three times. When roused up, the intelligence of the child seemed 
perfect. On the ninth day, the breathing was 63, and the pulse 120. There was 
rather more cough, though still very little, and there was a slight return of the 
coryza, of which there had been none for several days before. Neither auscultation 
nor percussion revealed any decided change in the lungs. On the eleventh day, 
the paroxysms of chilliness, followed by fever, were still noticeable, though there 
was no clearly marked perio<^city in the returns. When without fever the breath- 
ing was 54 ; during the fever it was 67. Auscultation revealed nothing decided. 
Percussion showed dulness beneath the right clavicle. By the seventeenth da}', the 
intermittent nature of the disorder was more decidedly marked, and under a few 
doses of quinine the symptoms had improved, so that the breathing fell to 30 during 
sleep. The cough was a little more frequent, though still very slight, and it was 
loose. The coryza, also, was more considerable, tlie nasal discharge being quite 
abundant. 

After this the case went on badly, owing, we think, in great measure, to the cir- 
cumstance of the quinine being abandoned in consequence of the opposition made 
by the parents to its administration, an opposition which we allowed to influence 
us more than was proper. During November and December, the child remained 
wpak, pale, languid, and with uncertain appetite, sometimes refusing the breast for 
a whole day at a time. The quinine was suspended at first on account of the great 
improvement which had taken place in the symptoms, and though resumed after- 
wards, was given in such small quantities, and for so short a time, for the reasons 
just mentioned, as to be of no service. In December the child was very ill. It 
looked badly, having a pale, waxy face, and a dull, languid expression, though 
without any want of intelligence ; it emaciated moderately, and had occasional 
vomiting; the stools were natural. At this time al.«o it took the mother'.s breast 
with some difficulty, and refused artificial food altogether. Occasionally during 
this month there was observed a slight blueno^s around the mouth, and also about 
the hands and feet. Late in the month it was attacked with thrush in a slight 
degree, which la.*ted several days. In the first week of January, finding that it 
was fast sinking from refusing the mother's breast and artificial food, a wetnursc 
was procured, and for a few da}* it seemed to improve a little, but this did not 
last. It grew weaker and thinner, the thrui»h returned, it had now a good deal of 
loose cough, the aMomen became somewhat contracted and f»'lt hard and doughy, 
and the breathing was very rapid, though not greatly oppressed. The child died 



148 COLLAPSE OF THE LUNG. 

at last on the 26th of January, having, for ten days before that event, looked 
wretchedly languid and haggard, and having presented for three days before, slight 
diarrhoea, loose, frequent cough, entire loss of appetite, thrush, drowsiness, and, 
finally, coma. 

At the autopsy there were found some fibrinous exudation, and a few adhesions 
over the lower half of the left lung. The lower two-thirds of the left and the 
lower half of the right lung were dark-colored, more dense than usual, not friable, 
and exhibited no granulations on a cut surface. These portions were in fact col- 
lapsed. The upper lobes were spongy, crepitant, and healthy. Not a tubercle 
was found. The foramen ovale presented an oval-shaped opening, of the size of a 
goose-quill. The abdominal organs were healthy. 

When, as indeed most usually happens, collapse occurs in the course of 
bronchitis, it is associated of course with the symptoms of that disease. 
The bronchitic symptoms have lasted in their usual form for several days, 
having been marked by sonorous, sibilant, and subcrepitant rales, when 
suddenly, or in the space of a few hours, the breathing becomes much 
worse, the pulse rises in frequency but becomes small and feeble, and cer- 
tain changes take place in the physical signs which are very important. 
The subcrepitant rale continues to be heard, but it is associated now with 
prolonged expiration, and a little later with bronchial respiration, which, 
however, is of a different kind from the bronchial respiration of pneumo- 
nia, being distant and smothered, instead of near and metallic, as in that 
disease. The percussion becomes, at the same time, dull and obscure, but 
never, scarcely, to the same extent as in pneumonia. The general symp- 
toms are those of exhaustion, rather than of high reaction. The surface 
is pale or slightly bluish, the skin is either natural in temperature, slightly 
warmer than usual, or coolish, the strength is very much reduced, and the 
child appears more seriously ill, and particularly more oppressed than the 
amount of bronchitis present would seem to explain. 

As an example of collapse occurring in the course of bronchitis, we will 
give the following case : 

A girl between two and three months old, healthy when born and up to the time 
of this sickness, saving that she was rather paler and smaller than most robust in- 
fants, was seized with coryza and slight cough, and after a few days with the symp- 
toms of a mild bronchitis. For two daj's there was frequent cough, some little 
fever, quick but not oppressed breathing, occasional sibilant and mucous rale, per- 
fect ability to nurse, and very moderate restlessness or fretfulness. On the third 
day, without any apparent reason, the symptoms became suddenly very alarming. 
The breathing became extremely rapid and most violently oppressed, so that the 
movements of the chest at each respiration were heaving and laborious, the shoul- 
ders being lifted high at each respiration, the outer angles of the mouth drawn 
downwards, and the alse nasi widely dilated. There were at the same time abund- 
ant subcrepitant, intermingled with dry rales over the dorsum of the chest. There 
was marked constriction of the base of the chest with each inspiration. The cough 
was frequent and racking, and occurred in paroxysms. The child was still and 
quiet, pale, had a haggard and exhausted look, was unable to nurse at all, and its 
surface was cool and white, especially that of the extremities. These symptoms 
continued with very little modification for twenty-four hours, when, under the use 
of brandy administered every hour in milk drawn from the mother, of the spirit 
of Mindererus and paregoric, perfect quiet, and the assiduous employment of mild 
revellents, they began to moderate, and at the end of another twenty-four hours 



I 



DIAGNOSIS. 149 

the constriction at the base of the thorax diirins: inspiration had disappeared, the 
breathing was easy and gentle, the extremities had become warm, the child nursed 
eagerly and abundantly, and, with the exception of a slight catarrh, which lasted 
a few days longer, it was well. 

Collapse depending on bronchitic iuflamraation, in debilitated children, 
may sometimes last a considerable length of time. In one case, indeed, 
that we saw a few years since, and of which an account was published (see 
Am. Journ. Med. Sci. for January, 1852, p. 98\ the symptoms, owing 
probably to the fact that the bronchitis causing the collapse was an ac- 
companiment of hooping-cough, continued with slight variations in degree 
for a period of about three months, after which the child entirely recov- 
ered. 

Diagnosis. — The diagnosis of collapse of the lung must always be more 
or less uncertain where it is of the lobular form, for the reason that the 
collapsed lobules being disseminated irregularly through the pulmonary 
tissue, afford no physical sign by which we can detect their condition. 
The presence of this form ought, however, to be suspected whenever, in a 
chronic disease, and especially m the course of a catarrhal attack occur- 
ring in a feeble and debilitated child, the breathing becomes excessively 
quick and labored, the skin pale and coolish, when the base of the thorax 
presents a depression instead of an expansion during inspiration, and, espe- 
cially, when these sN^mptoms occur without there being a sufficiently severe 
and extensive bronchitis to explain their existence. 

In cases of collapse affecting a considerable or the greater part of a 
lobe, the diagnosis, though still perhaps rather uncertain, is much more 
clear and positive than in the lobular form. In the latter form we are 
obliged to depend, indeed, almost exclusively upon the rational symptoms, 
the physical signs being either very slight or entirely null. In collapse of 
CDnsiderable portions of the lung-tissue, we have, on the contrary, some 
very useful physical signs. These are, the existence of dulness, greater or 
less, on percussion; feeble respiratory murmur; prolonged expiratory 
sound, and .sometimes bronchial respiration ; which, when they occur in 
connection with, and in the course of bronchitis, are usually quite suffi- 
cient to render the diagnosis easy. 

The only diseases with which collapse of the lung, presenting the physi- 
cal signs just mentioned, could be confounded, are pneumonia and pleurisy. 
From lx>th of these it is usually distinguishable by the absence in collapse, 
or the slight severity, of the reactional .symptoms, by the paleness or blue- 
nes and coolness of the surface, by the absence of acute pain, by the 
greater severity in collapse of the bronchitic symptoms, and by the fact 
that it rarely occurs except in enfeebled, broken-<lown subject,-*, or in tho.^e 
laboring under .severe bronchitis. The character of the phvsical signs, 
moreover, is different. Though we have dulness on percussion in collapse, 
it is not !K) absolute as that either of pleurisy with large effusion, or that 
of confirmed pneumonia. The bronchial respiration, too, is in collapse 
different from that of pneumonia. It is muffled and distant, instead of 
being clear, metallic, and close under the ear, as in pneumonia ; and is 
beard, too, much more in the expiration than in inspiration. In collapse 



150 COLLAPSE OF THE LUNG. 

there is also heard, unlike either pneumonia or pleurisy, an abundant sub- 
crepitant rale. To add to these differences, it is proper to say that, in cases 
of pneumonia and pleurisy, the course of the disease is much more regu- 
lar, and the special symptoms so well marked as to leave no doubt as to 
the real nature of the attack. 

Prognosis. — The prognosis of collapse must depend, in great measure, 
on two circumstances, — the amount of bronchitis which accompanies it, and 
the constitutional state of the child. When it occurs during the course of 
extensive bronchitis, as shown by a great abundance and extent of the 
bronchitic rales, it must add greatly to the danger of that disease ; and if, 
at the same time, the child be weak and debilitated, either from causes 
long previously in action, or from the severity of the present attack, the 
risk to life is very great indeed. Collapse is dangerous, also, but far from 
necessarily fatal, in subjects in whom its chief cause has been simple de- 
bility. The possibility and the probability of recovery will depend on the 
hygienic conditions to which the child is exposed, the degree of vital 
strength it is likely to inherit from its parents, the extent of the collapse, 
as indicated by the severity of the thoracic symptoms, both rational and 
physical, and the effects of treatment. When the subject can be placed 
under favorable hygienic conditions, when it has inherited from its parents 
a good and vigorous hold on life, and when the symptoms of collapse are 
not very violent, a proper and rational treatment will in all probability 
save it, while, under opposite circumstances, the chance of recovery would 
be very small, if there were any. 

Treatment. — The treatment of collapse, or post-natal atelectasis, must 
vary somewhat in different cases. One general rule will apply, however, 
to all ; that is, to employ a sustaining and strengthening system of medi- 
cation, to the exclusion of all exhausting means. 

In cases which are entirely, or almost entirely, independent of bronchitis, 
the most important measures to be attended to are the regulation of the 
temperature in which the child is kept, of the clothing, and of the diet, 
the use of mild stimulants and of tonics, and the external employment of 
revellents. The child ought to be kept in a warm, even temperature of 
from 70° to 75°; it should be clothed in soft flannels, and its diet ought to 
be nourishing and strengthening. If at the breast, we should be sure that 
the milk is of a good quality, and that the nurse has an abundant flow. 
If weaned recently, it ought to have, if possible, a wet-nurse, and so also 
if it be supposed that the mother has too little milk, or that this is not 
perfectly healthy. If permanently weaned, the diet should be so arranged 
as to give to the child what is at the same time easy of digestion and nu- 
tritious. In a severe case, coming on suddenly, the most suitable internal 
remedies are brandy, in small doses, frequently repeated ; quinia in full 
doses, or Huxham's tincture of bark, the spiritus Mindereri or the aromatic 
spirit of hartshorn, or carbonate of ammonia given in emulsion. In slower 
and more chronic cases, we must depend on a well-selected and nutritious 
diet (and food ought to be given almost by force, or at least it should be 
urged strongly on the child), on warm clothing, and on the use internally 
of brandy, quinine, the citrate of iron and quinine, pure metallic iron, the 



li 



I 



TREATMENT. 151 

iodide of iron, Hiixham's tincture of bark, or some such remedy. In sud- 
den cases, the best re%'ellents are the IblKnviiiu: : mustard weakenetl by- 
admixture of Hour or Indian meal, and api)lied once in three or four 
hours; a plaster made of suet or simple cerate grated over with nutmeg ; 
or liniments composed of ammonia, spirit of turpentine, or oil of amber, 
mixed with sweet oil. In chronic cases, the Burgundy pitch, or compound 
Galbanum plaster, made somewhat weaker than those used for adults, 
should be applied over the front and back of the chest, or we may rub the 
thorax twice a day with any ordinary ammonia liniment, made, if neces- 
sary, rather more irritating than usual by the addition of some oil of 
monarda. The daily use of a gentle emetic of ipecacuanha has been rec- 
ommended, and supposed to prove useful, by emptying the bronchia of 
their secretions, and also by the fact that its operation induces several deep 
inspirations, and in that mode promotes the better performance of the re- 
spiratory act. AVe have never employed the emetic except in cases accom- 
panied with a good deal of bronchitis and consequent accumulation of 
mucus in the air-tubes, and not then when the prostration was very great.- 
In fact, the operation of any emetic is sometimes productive of so much 
exhaustion of the strength, as to cause us to hesitate in prescribing a 
remedy of that class ; though we can fully understand that the act of 
vomiting, if not followed by too much prostration, could scarcely fail to 
prove beneficial in collapse, by the strong efforts at breathing which it 
gives rise to, and also by the succussions it must impart to the lungs 
through the medium of the diaphragm. 

In cases of collapse occurring in the course of, or towards the termina- 
tion of severe bronchitis, the treatment must resemble a good deal that 
which we have just described as proper for the same condition, when it 
exists unassociated, or associated only to a slight extent, with that disease. 
AVhen the symptoms of imperfect expansion appear towards the termina- 
tion of, or after the patient has partially recovered from bronchitis, and 
when of course the strength is more or less reduced by the severity of the 
previous acute sickness, and also perhaps by the necessary measures of 
treatment, the case ought to be managed very much in the same way as 
has just been recommended for those in which the collapse was caused 
chiefly by exhaustion, and less by the presence of obstructing secretions 
in the bronchia. •Nourishing, but very light and digestible food ; mild 
stimulants, as small quantities of brandy or wine-whey ; the bitter tinc- 
tures, iron, or quinine, with counter-irritants to the surface of the chest, 
warm clothing, and repose, constitute the necessary and most reasonable 
remedies. When, on the contrary, the atelectasial condition- supervenes 
in the midst of extensive and severe bronchitis, we are called upon to treat 
at the same moment two morbid states, one consisting of active inflamma- 
tion, and another of want of p^)wer in the muscles of res[)iration to force 
the atmospheric air through the secretions which are obstructing the air- 
passages. Under these circumstances, there is almost always associated 
with the bronchiti.*, as we shall find when we come to treat of that diK-ase, 
more or less intense congestion of the collapsed prjrtions of the lungs. 
We must employ, therefore, such remedies as tend to modify the inflamma- 



152 COLLAPSE OF THE LUNG. 

tion of the bronchial mucous membrane, and diminish thereby the amount 
of secretion poured into the air-passages ; such as may serve to expel me- 
chanically those secretions ; and those which shall unload the congested 
lung of its excess of blood, always taking care, in our selection of the 
agents to accomplish these ends, to choose those which are the least per- 
turbative and exhausting. To moderate the inflammation of the bronchial 
mucous membrane, and with a view also to unload the congested parts of 
the lung, we may apply a few dry cups, or rely on counter-irritation, the 
best mode of effecting which is by the repeated application of mustard 
poultices, consisting of one-third mustard to two-thirds Indian meal or 
flour, and by mustard foot-baths. These poultices ought to be applied first 
to the dorsum and then to the front of the chest, once in every three or 
four hours, and they should be made l^rge enough to cover a considerable 
portion of the thoracic walls. Counter-irritation, assiduously made use of, 
is, we believe, one of the most, if not the most effectual means of treatment 
in the case. Emetics ought to be given twice a day, or even three times, 
if they do not reduce the strength too much. The best are those which 
operate with the least subsequent prostration, such as ipecacuanha or alum. 
When they are found to exhaust much, and to increase thereby the labor 
of breathing, their use must be suspended. 

After emetics, or when these cannot be used, the remedies from which 
we have obtained the greatest benefit are carbonate of ammonia or liq. 
ammon. acetat., and seneka, either in decoction or syrup, combined some- 
times with small quantities of opium. To a child two years old we should 
give one or one and a half grains of carbonate of ammonia or twenty 
drops of the acetate of ammonia solution, with ten of the syrup of seneka, 
or with a teaspoonful of decoction of seneka, every two hours. When the 
cough is paroxysmal, painful, and harassing, about ten drops of paregoric, 
half a drop or a drop of laudanum, or from four to six drops of solution 
of morphia, may be added to each of the above doses. The opiate ought 
to be continued until the cough and restlessness diminish, and then be sus- 
pended. In all these cases, there should be no hesitation in giving small 
quantities of brandy or wine-whey, whenever the symptoms of prostration 
are so marked as to indicate danger ; and these stimuli are urgently called 
for when the pulse is very rapid and small, when the skin is cool or pale 
and bluish, and when the general aspect of the patient, and the convulsive 
and labored character of the breathing, show that the muscular strength 
of the child is scarcely sufficient to carry on the function of respiration. 



PNEUMONIA. 153 



ARTICLE II. 

PNEUMONIA. 

Definition; Synonyms; Frequency; Forms. — The term pneumonia 
is DOW, by universal consent, applied only to inflammation of the paren- 
chymatous structure of the lungs. It is often called, in this country, 
catarrh-fever, lung-fever, or inflammation of the lungs. 

It is one of the most frequent, and, therefore, one of the most important 
of the acute diseases of childhood. Dr. West, in a paper on the pneu- 
monia of children {Brit, and For. Med. Rev., April, 1843), informs us that 
the English tables of mortality show pneumonia to be the cause of a larger 
number of deaths in childhood than any other disease, with the exception 
of the exanthemata. From the third report of the Registrar-General, 
he quotes the facts that of all the deaths in the metropolitan districts 
under fifteen years of age, 13.6 per cent, were from pneumonia, 13.0 per 
cent, from convulsions, and 5.4 per cent, from hydrocephalus. He ob- 
tained nearly similar results from an examination of the returns from 
Manchester, Liverpool, and Birmingham. 

In this city it appears from the bills of mortality that the deaths from 
this disease are strikingly below the percentage calculated by Dr. West, 
Thus, during the seven years ending with 1869, the total mortality from 
all causes fexcluding still-born children ) was, at all ages, 105,785 ; under 
fifteen years of age, 50,151 ; and under five years, 43,322, The total 
mortality from pneumonia during the same period was, at all ages, 5567, 
or 5.26 per cent, of the entire mortality ; under fifteen years, 2985, or 
5.95 per cent, of the mortality under that age ; and under five years, 
2746, or 6.33 per cent, of the mortality under that age. During the same 
series of years, the total mortality from bronchitis was, at all ages, 969, 
or less than 1 per cent, of the entire mortality ; under the age of fifteen 
years, 509, or 1.01 per cent, of the mortality under that age; and under 
the age of five years, 405, or 1.14 per cent, of the mortality duriiiL'" the 
first five years of life. 

Any one who will study with attention the various doctrinrs in r(';_'ard 
to pneumonia and bronchitis that have been set forth in the difl^crent 
works on the disease,s of children, will most assuredly acknowledge that 
there are few diseases about which there has prevailed so much diversity 
of opinion as to the real nature of the lesions forming the essential ana- 
tomical characters of the disorder, and, as a consequence of this, so much 
doubt as to the proper mode of classifying and de^scribing them. From 
the time of the appearance of the works of M. Valleix, M. Barrier, Dr. 
Gerhard, and especially that of MM. Rilliet and Barthez, up to the mo- 
ment of publication of the essay of MM. Legendre and Bailly (referred 
to in the article on atelectasis), it was commonlv believed that inflamma- 



154 PNEUMONIA. 

tion of the parenchyma of the lung exhibited in children very different 
characters in the majority of the cases, from those which marked the 
pneumonia of the adult. Two principal forms of the disease were there- 
fore described by most writers, — the lobular and the lobar. The former 
w^as supposed to be almost peculiar to children, and to occur only on i'are 
occasions in adults ; the latter was held to resemble, in almost every re- 
spect, the pulmonic inflammation of the adult. Moreover, lobular pneu- 
monia was generally believed to be by far the most common form assumed 
by the inflammation in children under five years of age, whilst lobar 
pneumonia was thought to be comparatively rare under the age men- 
tioned. Besides these two chief varieties of pneumonia, two others have 
been described under the names of vesicular and marginal pneumonia, 
while to yet another MM. Rilliet and Barthez applied the title of carni- 
fication. 

The researches of MM. Legendre and Bailly, published in 1844, caused 
a great revolution in the views of medical observers and writers. These 
authors first pointed out (as stated in the article on atelectasis) that a 
very large proportion of the cases previously described under the titles of 
lobular pneumonia, generalized lobular pneumonia, pseudo-lobar pneumo- 
nia, marginal pneumonia, and the carnification of MM. Killiet and Bar- 
thez, were in fact cases of bronchitis variously associated with congestion 
and collapse of the tissue of the lung. Since the publication of these 
views, the whole subject has been repeatedly investigated, and we believe 
that a general agreement now exists in regard to most of the important 
pathological questions connected with collapse of the lung and the differ- 
ent forms of pneumonia. We would refer any one who desires to study 
the progress of medical opinion on these important subjects to the able 
essay. On the Pathological Anatomy of Bronchitis and the Diseases of the 
Lung connected with Bronchial Obstruction, by Dr. W. T. Gairdner, of 
Edinburgh, and to the elaborate article in the second edition of the work 
of Rilliet and Barthez. We shall ourselves adopt the division of pneu- 
monia into the lobar and the catarrhal forms. The former of these is suf- 
ficiently understood as corresponding with the same form in the adult, 
while the latter corresponds with the form which we, in previous editions, 
described under the term partial, and which has also been named lobular. 
Despite the fact that formerly many cases of bronchitis with lobular collapse 
were regarded as cases of lobular pneumonia, it is probable that the catar- 
rhal form must still be regarded as of at least equally frequent occurrence 
in children as the lobar. In infants under the age of two years, pneumo- 
nia is especially apt to assume the catarrhal form. Rindfleisch, however, 
exceeds the truth in asserting that in children under the age of five, hardly 
any other form of pulmonary inflammation occurs {Pathological Histology, 
Syd. Soc. ed., vol. ii, p. 14). 

Predisposing Causes. — It is generally believed that pneumonia is most 
apt to occur in the course of other affections. This is certainly true in re- 
gard to both forms of the disease as it prevails in hospitals, and probably 
amongst the poorer classes of society also. MM. Rilliet and Barthez state 



PREDISPOSING CAUSES — INFLUENCE OF SEASON. 155 

that of two hundred and forty-five cases observed by themselves, only fifty- 
eight, or a little less than a fourth, occurred in children previously in good 
health. The proportion of cases in wliich lobar pneumonia occurs in pri- 
vate practice as a secondary aftection is much smaller, since of fifty-oue 
well*niarked case^, observed by oui-selves, in which this point was noted, 
only six were secondary. On the other hand catarrhal pneumonia is 
usually a secondary lesion, and frequently occurs as the result of an ex- 
tension of severe bronchitis. 

Age forms a strong predisposing influence. Of the two hundred and 
forty-five cases above quoted, one hundred and seventy-two occurred under 
five years of age. Dr. West {loc. cit.) says that during the first five years 
of life, the cases of pneumonia were in the proportion of 10.3 per cent, to 
the total of diseases, while in the succeeding five years they were in the 
proportion only of 1.3 per cent. The mortality bills of this city exhibit 
the same marked excess in the proportion of deaths from pneumonia under 
five years of age, as compared with the ensuing years. We have already 
seen that the proportion during the fii'st five years of life is 6.33 per cent, 
of the entire mortality under that age ; while during the ensuing ten years 
the deaths from pneumonia form but 3J per cent, of the total mortality 
during that period of life. These statements do not agree with our own 
experience in private practice, since of fifty-five cases that we have seen 
in which this point was noted, twenty-eight occurred under five, and twenty- 
six between five and eleven years of age, showing that the frequency in 
the first five and the subsequent six yeai*s of life is very nearly the same. 
Lobar pneumonia is much less frequent in private practice in the first two, 
than in the succeeding years of life. 

Sex. — A larger number of cases occur in boys than girls. The excess 
is probably not more, however, than may be accounted for by the prepon- 
derance of male over female children. Of fifty-five cases of the lobar 
form in which we have noted the sex, thirty occurred in boys, and twenty- 
five in girls. 

Comtitution. — It is doubtful whether constitution has much or any in- 
fluence upon the liability to the disease. Dr. West says that weak health 
is not a predisposing cause, according to his experience. We are con- 
vinced that lobar pneumonia attacks strong and vigorous children more 
frequently than those of more delicate constitution. In children of feeble 
health and weak stamina, the very same causes which produce pneumonia 
in the robust, give rise to bronchitis, or perhaj)? to catarrhal pneumonia. 

Sewton. — The disea.se is most prevalent during the winter and early 
spring months, as will be seen from the accompanying table, in which is 
shown the mean monthly mortality in Philadelphia, for the seven years 
ending 1870, from this disease, as well as from bronchitis. From this it 
will be i*een that in December, January, February, and March (and the 
same is very nearly true of April also), the deaths from these diseases aro 
three times as numerous as in August. 



156 





PNEUMONIA. 






Mean monthly 

mortality for 7 years, 
from Pneumonia 
and Bronchitis. 


Mean total 
mortality from all 
causes (includ- 
ing still-born) 
for 7 years. 


Mean monthly 
percentage for 7 

years, from 

Pneumonia and 

Bronchitis. 


Mean monthly 

temperature 

(F.) for 7 years. 


Pneumonia, , 
Bronchitis, 


. 46 
. 6.29 


1296.71 


8.54 
0.48 


30.87° 


Pneumonia, . 
Bronchitis, 


, 45.57 
. 8.43 


1206.71 


3.76 
0.69 


33.89° 


Pneumonia, . 
Bronchitis, 


, 48,57 
, 7.14 


1344.29 


3.61 
0.53 


40.85° 


Pneumonia, , 
Bronchitis, 


, 41.57 
, 5.71 


1281.14 


3,24 
0.44 


52.27° 


Pneumonia, , 
Bronchitis, 


. 34.76 
, 6.57 


1234.29 


2.81 
0.53 


62.77° 


Pneumonia, . 
Bronchitis, 


, 26.14 
, 5.00 


1178.14 


2.21 
0.42 


71.97° 


Pneumonia, , 
Bronchitis, 


, 24.14 
. 4.00 


1837.00 


1.31 
0.21 


77.71° 


Pneumonia, . 
Bronchitis, 


20.14 
3.00 


1825.43 


1.10 
0.16 


76.62" 


Pneumonia, . 
Bronchitis, 


14. .57 

5.29 


1215.43 


1.19 
43 


68.31? 


Pneumonia, . 
Bronchitis, 


22.43 
, 5.43 


1218.14 


1.84 
0.44 


56.30° 


Pneumonia, , 
Bronchitis, 


. 28.86 
, 5.71 


1052.14 


2.74 
0.54 


46.68° 


Pneumonia, . 
Bronchitis, , 


39.57 

. 8.14 


1191.00 


3 32 
0.58 


34.74° 



Months. 

January, . 
February, 
March, . . 
April, . , 
May, . . . 
June, . . . 
July, . . . 
August, . 
September, 
October, . 
November, 
December, 



We have also placed in parallel columns the mean percentage of mor- 
tality from these two diseases, and the mean monthly temperatures, in 
order to show the marked correspondence between the coldness of the 
weather and the frequency of pneumonia and bronchitis. It is evident, 
however, that there is another element, besides the mere temperature, in 
determining their frequency, since, in both February and March, more 
deaths occurred from these causes than in January, although this latter is 
the coldest month of the year. The additional element is undoubtedly to 
be found partly in the sudden atmospheric changes, and damp raw days 
which are so frequent, in both February and March, in our latitude, and 
partly in the impaired vitality found in many children, as the result of the 
intense cold of the preceding months. 

Previous Diseases. — It is apt to occur as a complication of all the dis- 
eases of children, and most frequently in measles, pertussis, typhoid fever, 
enteritis, and bilious remittent fever. We have already stated that the 
catarrhal form is very frequently consequent upon severe bronchitis. 

Exciting Causes. — The continued action of some of the predisposing 
causes must be regarded as the exciting cause in the majority of the cases. 
External violence, as a severe fall, or a blow upon the chest, will sometimes 
act as an exciting cause. The action of cold is almost always alleged to be 
the immediate cause of the attack. M. Grisolle states that it is impossible 
to determine the exciting cause in more than a fourth of the cases, and that 
in nearly all of these it is cold. 

Anatomical Lesions. — Lobar pneumonia in the child is marked by 



AXATOMICAL LESIONS. 157 

the same physical characters as in the adult. The three stages of the in- 
flaiiimatiou — engorgemeut, red hepatization, and gray hepatization — ex- 
hibit the same alterations of the tissues as in adult life. ^loreover, the 
three stages occur with about the same frequency in early as in later life. 
Dr. West \^loc. cit.y 2d ed., p. 189) shows that the third stage occurs very 
uearly as often in children as in adults, he having met with it in the for- 
mer in the propi^rtion of sixty-eight per cent., while ]M. Grisolle found it in 
seventy-two per cent, of the latter. The chief ditference in the disease, as 
it exists at the two ages, consists in the more frequent coexistence of all 
three of the stages; in the young subject. 

In the first stage, or that of engorgemeut, the affected portion of lung is 
distended, so that it does not collapse in the same proportion as the healthy 
portions, when the thorax is opened. It is heavier than usual, so that it 
sinks somewhat in water ; it is of a brownish-red color ; it pits upon pressure, 
and crepitates less than healthy lung, the crepitation being observable only 
here and there. The natural degree of cohesion between the tissues is some- 
what diminished, so that the diseased portion is much less tough and elastic, 
and more soft and friable than it ought to be. When cut into, a large 
quantity of frothy, and more or less deeply-tinged sanguineous fluid escapes. 

In the second stage, or that of red hepatization, the lung is increased in 
volume, so that it continues to fill the side of the chest after that cavity is 
opened ; it is dense and hard, has ceased entirely to crepitate, from the fact 
of having become completely impermeable to air, and sinks rapidly when 
thrown into water. Externally, the diseased portion is of a deep-red color, 
while internally the same color is observed, but often of such different 
shades as to give to a cut surface a marbled aspect. The cohesion be- 
tween the tissues is, in this stage, much less strong than in health or in the 
first stage of the disease ; the finger penetrates the lung with some ease, and 
the texture can be crushed between the finger and thumb. When cut into, 
there escapes a non-aerated and reddish fluid, which is much less abundant 
than in the first stage. The most important feature of red hepatization is, 
however, the granular character of an incised surface. This granular ap- 
pearance is produced by the presence of numerous minute flat granular 
elevations, which are the air- vesicles distended with the plastic lymj)h 
which has been exuded within them. It is best seen by examining a torn 
surface of the lung. The most recent investigations tend to show that 
while some part of the exudation which distends the vesicles may be due 
to the multiplication of the epithelial cells lining their walls, the greatest 
portion Ls derived directly from the blood and either escapes tli rough the 
walls of the vessels without rupture or, to a small extent, is associated with 
rupture of the capillary walls. The exudation itself is seen, on microscopic 
examination, to have a finely-fibrillated structure inclosing a nund)er of 
red and colorless corpuscles. (Rindfleisch.) 

In the third stage, or that of gray hepatization, the lung continues to 
exhibit the same volume, density, impermeability to air, and consequent 
total abseDce of crepitation, as in the second ; but the process of softening 
ha- made still further progress, »o that a portion of the lung may be 
squeezed with the greatest ease between the finger and thumb into a pulp. 



158 PNEUMONIA. 

The color has now changed from deep-red to a dirty light-gray, or a pale 
straw-yellow. When incised, the surface still presents a granular appear- 
ance, but the granules are more irregular and flatter. The diseased por- 
tions are now infiltrated with a puruloid fluid, which escapes in considerable 
quantities in the form of a yellowish-gray liquid, whenever the lung is cut 
into. 

Occasionally instead of lobar pneumonia involving an entire lobe or a 
considerable portion of one continuously, it presents itself in the form of 
several scattered patches, irregular in form and imperfectly circumscribed, 
but which present the three stages above described, of engorgement, red 
hepatization, and gray hepatization. 

On the other hand, in catarrhal pneumonia there is not the same pro- 
cess of free exudation into the air-vesicles, but instead there is a rapid 
multiplication of the alveolar epithelial cells which soon fill the vesicles. 
The accumulated cells are mixed with some sero-mucous secretion, but there 
is found little or no trace of fibrillation, such as is present in the exudation 
of the lobar or croupous form. The catarrhal inflammation aflfects separate 
lobules, and then gives rise to nodules scattered over and through the lung. 
These vary in size, from that of a hemp-seed, if a single lobule be affected, 
even to that of a pigeon's egg, if a large number of affected lobules coalesce. 
At first they present a reddish or reddish-gray appearance; but later, owing 
to fatty changes in the proliferated cells, the color changes to a grayish or 
yellowish-gray. This change may at times occur in the centre only of the 
nodule, or over its whole extent, or again on its circumference. If the case 
is destined to end favorably, the cells, after having undergone complete 
fatty change, are absorbed, or else, an excess of serum being present, may 
be discharged into the bronchioles and expectorated. The alveolar wall 
returns to its original condition and a perfect cure is eflfected. Or, on the 
other hand, the. changes in the alveolar wall persist, the contents of the 
alveoli undergo cheesy or caseous metamorphosis, and the case passes into 
a chronic and highly unfavorable stage. 

Abscesses are not very uncommon in the lobar pneumonia of children. - 
They occur as a result of the third stage of the disease, so that in the same 1 1 
lung may be observed the first, second, and third stages of the inflamma- 
tion, and abscesses. The cavities of the abscesses are generally circular, 
sometimes oval, and they measure from half a line to an inch or more in 
diameter. Sometimes the abscess is multilocular, each of the purulent 
cavities being partially separated from its neighbor by a wall of hepatized 
tissue. They are found in various parts of the lung, but seem disposed, 
generally, to approach the surface of the organ. When the latter event 
happens, adhesive inflammation between the pulmonary and costal pleura 
usually takes place ; but should this fail to occur, the abscess may rupture 
into the pleural sac, and produce pneumothorax. MM. Killiet and Barthez 
met with two examples in their autopsies in which this accident had 
occurred, and they report another case in which it occurred during life, 
and in which the child recovered. We have met with three cases of pneu- 
mothorax ourselves, produced in the same way. One occurred in a boy 
eleven years old, during an attack of secondary pneumonia complicating 



ANATOMICAL LESIONS. 159 

a severe bilious remittent fever. The patient recovered entirely after a 
most violent illness. The two others occurred in very young children, and 
proved fatal. 

We are desirous, before closing our remarks on the anatomical lesions 
of the disease under consideration, of drawing attention to the subject of 
simple nou-intlammatory congestion of the lung, for the reason that the 
latter has no doubt, especially when associated with collapse of the pul- 
monary tissue, been frequently mistaken for pneumonia. 

Congestion of the lung occurs either in the lobular or lobar form, the 
distinction between the two being the same as that between lobular and 
diflused or lobar collapse. When lobular, the lung presents, generally 
along the posterior edge of the organ, disseminated lobules, distinctly 
circumscribed by the interlobular cellular septa, which are rather protu- 
berant than depressed, more friable, and of a lighter purple color than 
collapsed lobules, and which afford, when squeezed, a considerable quan- 
tity of frothless bloody fluid. In very young infants, the congestive dis- 
position often assumes the lobar or diffused form, and is supposed by M. 
Legendre to have frequently been taken for pneumonia. In this variety 
of congestion, the affected portion of the lung is increased in size, and is 
distended and gorged with fluids. The color of the congested part varies 
from a light to a dark purple, or almost blackish tint. The cohesion of 
the lung is also variable, the differences depending on the degree of the 
congestion. When this latter is very great, the part is very friable, while 
it is much less so under the opposite condition of things. Though the 
lung is harder in this state than natural, it still retains a certain degree of 
flaccidity which does not exist in true hepatization. Pressure causes an 
abundant exudation of blood and serosity from a cut surface, and the 
latter, instead of being granulated, as is always the case in hepatization, 
is smooth and even. Neither does the lung exhibit any granulations when 
it is torn. Lastly, inflation distends all the vesicles, and gives to the con- 
densed parts their natural lightness and their rosy color, though, be it 
remarked, the development of the affected parts under the operation is not 
complete and entire, as in collapse, in consequence, no doubt, of the large 
amount of blood they contain. 

Inflation of the lung after death has been much employed of late, as 
any one who has read the previous remarks on atelectasis must have seen, 
as a means of distinguishing between pneumonia and collapse. It was 
there stated that, whilst inflation distended and restored more or less 
completely to their natural condition parts of the lung that were merely 
collapsed, it failed almost entirely to have any effect on parts of the lung 
affected with true pneumonia. It is easy to understand why inflation 
should fail to exert much effect on inflamed lung, at least when the dis- 
ease has reached the state of hepatization. In fact the alveoli are dis- 
tended either with the croupous exudation of the lobar form, or the accu- 
mulated epithelial cells of the catarrhal form, so that it becomes impossi- 
ble to force the air into the midst of the agglutinated structures. In the 
first stage of pneumonia, that of congestion, inflation will distend in some 



160 PNEUMONIA. 

degree the affected portions, but, in the second and third stages, not even 
the strongest force has any effect on the impermeable vesicles. 

Lobar pneumonia is stated by most authorities to be generally confined 
to one lung, and such has been our own experience in regard to it, since of 
56 cases in which its location was carefully determined, it was unilateral 
in 52, and double only in 4. It is much more common on the right than 
left side, according to most writers. In the 52 cases just referred to, the 
distribution was nearly equal, the disease being seated 29 times on the 
right side, and 23 times on the left. It attacks the lower lobe much more 
frequently than the upper, though pneumonia of the upper lobe is much 
more frequently met with in children than in adults. Of 51 cases in 
which this point was determined, the upper lobe was the part affected in 
20, while in 31 the base of the lung was the seat of the disease. Of the 
20 cases of inflammation of the upper lobe, in 13 it was seated on the 
right, and in 7 on the left side. Of 31 cases occurring in the lower lobes, 
15 were on the right, and 16 on the left side. In the 4 cases of double 
pneumonia, the inflammation attacked the lower lobes of both lungs in 
one; in one the postero-inferior part of both upper lobes was especially 
involved ; while in the two others it attacked first the base of the left lung, 
and afterwards the summit of the right. 

The statements just made as to the seat of the pneumonic inflammation, 
in the cases that have come under our own observation, do not, we are 
well aware, agree exactly with the experience of other observers. Dr. 
West, for instance, found {loe. sit, p. 190) that double pneumonias pre- 
ponderated greatly, in early life, over those wherein only one lung suf- 
fered. This, it will be observed, is widely different from the result of our ex- 
perience, and it is also directly opposed to that of MM. Rilliet and Barthez, 
Rufz, and Barrier. M. Barrier, in fact, cites (Mai. de L'Enfance, t. i, p. 
286) 144 cases of lobar pneumonia as having been observed by the authors 
just mentioned, and by himself, and of these only 15 were double. Our re- 
sults in regard to the frequency of double lobar pneumonia agree, therefore, 
with those of the authors last mentioned, but they differ as to the relative 
frequency with which the two lungs are attacked. Thus, in our cases, the 
inflammation occurred with nearly equal frequency in the two lungs, whilst 
of 129 cases of unilateral pneumonia observed by the above authors, 84 
were seated in the right, and 45 in the left lung. These writers state, 
as most others do, that lobar pneumonia of the lower lobe is more com- 
mon than that of the upper lobe. This tallies with our observations, 
but, as it seems to be a general opinion in the profession, that inflamma- 
tion of the summit of the lung is rare in comparison with that of the base, 
we wish to call attention again to the fact stated above, that of 51 cases, 
in which we ascertained accurately the seat of the disease, it was in the 
upper lobe in 20, and in the lower in 31. 

In regard to catarrhal pneumonia, the statement of West above quoted 
is certainly true, and it is frequently found that both lungs are involved, 
and in some cases that there is a more or less symmetrical disposition of 
the affected nodules. 

In the lobar pneumonia of children, as in that of adults, bronchitis does 



LOBAR OR CROUPOUS FORM. 161 

not usually exist to auy very considerable extent. It is true that before 
the recognition of the true nature of collapse of the luug, the association 
of bronchitis and lobar pneumonia was thought to be more frequent, be- 
cause a considerable number of case^ of bronchitis with extensive collapse 
of lung-tissues were regarded as instauces of true lobar pneumonia. 

But, on the other hand, although the catarrhal form may occur without 
any associated bronchitis, it is undoubted that bronchitis does very fre- 
quently precede or accompany the development of the catarrhal inflam- 
mation of the alveoli. 

When bronchitis is present it varies from simple increased vascularity 
with augmented mucous secretion, to intense congestion with purulent or 
pseudo-membranous secretion. 

P/ewnVy is a frequent complication, as it is found to exist in about half 
the cases. 

Emphysema is another common complication. It generally occupies 
the upper part of the lung, or its free edge, and is found most strongly 
developed in the lung which presents the greatest amount of inflam- 
mation, or in both, when both are inflamed. Its degree depends on the 
extent of the pulmonary inflammation and bronchitis, and the severity of 
the dyspncea. The vesicular form is much more frequent than the inter- 
lobular. 

Symptoms; Sketch of the Disease ; Course. — In order to present a 
faithful account of the disease in its difl?erent forms, a general sketch of 
the symptoms will first be given, after which the most important ones will 
be considered separately under the head of particular symptoms, so that 
the reader may first obtain a notion of the coui-se of the disease, and then 
become intimately acquainted with its details and peculiarities by reference 
to the remarks on each particular symptom. 

Lobar or Croupous Form. — True lobar pneumonia, with well-marked 
hepatization, is not, according to our experience, a common affection in 
young infants in private practice, since out of fifty cases of the disease that 
we have met with in children, in which we have noted this point, only two 
occurred in infants within the first, and three in the second year. Of the 
two cases within the year, one occurred in a child six weeks old, and the 
other in one seven mouths. 

In neu'-born children, and those siiil at the breast, pneumonia is apt to be 
of the catarrhal form, and very generally begins with more or less marked 
symptoms of bronchitis, though in some instances it commences suddenly, 
a^ it does in adults, without any previous sign whatever of bronchial in- 
::amraation. When it occurs during an attack of bronchitis, the symptoms 
which belong to the pneumonic inflammation will, of course, have been 
preceded by those which def)end on the disease of the bronchial mucous 
membrane. In these cases, the development of the pneumonia will be in- 
dicated by an aggravation of the general symptoms, by an increase of fever 
with elevation of the temperature, by an increase of the oppression, by the 
fact that the cough and breathing l)oth become more painful than before, 
and in some cases by the occurrence of the physical signs jKculiar to lobar 
pneumonia. In these latter cases, which are very rare, the character of the 

11 



162 PNEUMONIA. 

physical signs and the course of the case is very much such as are described 
below. 

When lobar pneumonia appears as a primary affection in young chil- 
dren, without preceding bronchitis, as sometimes undoubtedly happens, 
though much less frequently than in children over five years of age, and 
especially than in adults, the attack is usually sudden. The first symp- 
toms observed are restlessness, peevishness, disposition to cry, a diminished 
appetite for the breast, and feverishness. These symptoms are most 
marked in the evening and night. From the very first, or by the second 
day at least, cough is heard, and careful examination of the breathing 
will show that it is somewhat hurried. The cough is dry, short, and 
hacking, at first, and not very frequent, but it soon becomes louder, fuller, 
more straining, and especially it becomes painful. The fact that it is 
painful may always be ascertained by watching the motions of the child, 
its cry, and the expression of the face. We can always perceive, even in 
an infant, a disposition to restrain the cough, to smother it, a struggle to 
make it short and sudden, when it causes sharp pain. At the moment of 
the cough, too, a marked expression of pain, a kind of sudden grimace or 
twisting of the features, may always be observed, which is accompanied or 
followed instantly by a loud, sharp cry, or a spell of crying. This grimace 
of pain, with the accompanying cry, we have never observed in their most 
characteristic form in simple bronchitis, but only in pneumonia and pleu- 
risy. We have occasionally seen these symptoms so decidedly marked 
that they could not fail to have drawn any one's attention ; as, for exam- 
ple, in an infant six weeks old, who died of a most violent and extensive 
pleuro-pneumonia, and again in a child thirteen months old, who died of 
pleurisy resulting in the formation of pure pus in the pleural sac. The 
nature and extent of the lesions were ascertained, in both cases, by ex- 
amination after death. The presence of pain in the side is shown also by 
the fact that full inspirations, caused by changing the position of the 
child, and those which occur during fits of crying, occasion a sudden 
arrest or stoppage, so to speak, of the act of inhalation, which gives to 
the crying, and often also to the breathing, a sobbing character, while 
across the countenance passes at the same moment the expression of pain 
already referred to. The breathing, which is only slightly disturbed at 
first, soon becomes frequent and attended with more or less effort, and 
gives rise to an unusual play of the nostrils, a symptom which ought 
always to attract attention to the respiratory system as the seat of dis- 
order. It interferes also with the act of nursing, so that whether the 
child takes the breast less frequently than usual, from want of appetite, 
or seeks it with greater avidity than common, from thirst, the act of suck- 
ing is attended with some difficulty. The infant seizes the breast for a 
few instants, then lets go in order to breathe more easily, and seizes it 
again ; or it drops the nipple suddenly and begins to cry, as though the 
act of sucking were painful from the necessity it begets of taking occa- 
sionally a fuller and deeper inspiration than usual. As a general rule, 
the bowels are torpid, while vomiting, which is rather unusual in older 
children, is quite common in young infants. 



^ 



SYMPTOMS. 163 

When the disease is once established, whether it have been preceded by 
bronehitic symptoms, or occur as a primary affection, the symptoms are 
generally well marked, so as to leave but little difficulty in the recogni- 
tion of the disorder. The child now loses all gayety and cheerfulness, and 
becomes either dull and listless, or very restless, peevish, and troublesome. 
Young infants generally lie quietly on the bed, or in the lap, merely fret- 
ting and crying when they cough, or when they are moved for any purpose, 
while children of several months old, and those in the second year, are 
usually very cross and restless, crying and screaming when anything is 
done for them, and insisting upon being frequently moved from the cradle 
or bed to the lap, or from the lap to the cradle. As a general rule they 
are contented only upon the lap, always crying to get back when they are 
removed from it to the cradle or crib. In some instances, however, they, 
like young infants, are quiet and dull, being content to lie still when placed 
in a comfortable position, and crying only after coughing, for the breast or 
drink, or when disturbed. 

A febrile reaction now displays itself in full force. The skin becomes 
hot and dry, and the pulse frequent, rising to 150 and 160, or higher, in 
infants, and to 140 and 150, or even 160, in those of several months old. 
The temperature rises very quickly, so that by the close of the first twenty- 
four hours it may reach 104^^, 105°, or even 105.8"^ (Roger). The dysp- 
noea becomes more and more evident. The respiration rises to 60, 70, 80, 
or even higher. In a case of pleuro-pneumonia at six weeks of age, we 
counted it at 128. The breathing is at the same time more or less labored 
and difficult, the ahe nasi being seen to dilate spasmodically at each inspi- 
ration, while the motions of the chest, and especially those of the abdomen, 
are much stronger and more active than in healthful respiration. The 
cough is now more frequent than before, evidently painful, and usually 
dry, though sometimes a slight degree of looseness may be detected in the 
-ound which it occasions. 

Percussion now reveals manifest dulness over the seat of disease, which 
is iLsually the base, though not at all unfrequently the upper region of one 
-ide. When the disease is double, which is oftener the case, as already 
stated, in children than in adults, though not so often as has been sup- 
posed by some, the percussion will be dull of course over the affected region 
on each side. Together with the dulness of sound on percussion, and sorae- 
" - when this is faintly marked, there is an evident diminution of the 

-licity of the walls of the chest, and this becomes, therefore, an impor- 
tant symptom, especially when dulne.s8 on percus.sion is absent. The dul- 
ness on percussion is not, indeed, so marked a symptom in infants as in 
adults, from the fact that the natural resonance of the chest is so much 
greater in the former than the latter. 

Auscultation reveals over the diseased part distinct and abundant fine 
subcrepitant rale; but the crepitant rAle or fine crepitation, which is the 
pathognomonic sign of pneumonia in adulti*, and which in them is rarely 
wanting, is absent in young children, or is hoard only when they make 
deep and free inspirations. It is most apt to be heard in young children 
during the deep inhalations which they make just before crying, or during 



164 PNEUMONIA. 

the act of crying. It is, therefore, much less constant, less strongly marked, 
and more fugitive, in children than in adults, and is, in the former, replaced 
in good measure by a fine subcrepitant rale. In connection with these 
symptoms we always have more or less well-marked bronchial respiration. 
This may be pure, which is rarely the case ; it may be, as usually happens, 
associated with crepitant or subcrepitant rales, or it may be heard only in 
the expiration. 

The symptoms above described show that the inflammation has reached 
the second stage, or that of red hepatization. After attaining this point, 
the disease usually remains stationary for a few days, and then either sub- 
sides, in favorable cases, by the resolution of the inflammation, or in un- 
favorable cases, terminates fatally in this stage, or else passes into the 
third stage and causes death by a more or less extensive suppuration of 
the lung. In favorable cases, which are said to be rare in very young in- 
fants, but more common in those several months old and in the second year 
of life, the severity of the symptoms gradually diminishes. The fever sub- 
sides, the pulse becoming less frequent, and the skin cooler and less dry ; 
the breathing becomes easier and slower, and is attended with less pain ; 
the cough grows looser, less frequent, less difficult, and ceases to be pain- 
ful ; the child begins to nurse without pain and with greater ease and fa- 
cility ; the restlessness and fretfulness, or the somnolence, when that has 
been a marked symptom, diminish, and the child becomes more placid, 
and sleeps quietly and tranquilly. The chest is now less dull than before 
on percussion; the bronchial respiration begins to diminish in intensity, 
and is very much masked by the subcrepitant rale, which becomes more 
and more evident, until at last it takes the place entirely of the bronchial 
breathing. The symptoms continuing to amend, the physical signs of the 
disease cease at length to be perceptible, the cough grows more and more 
loose and rare, the countenance becomes natural, the fever ceases, and con- 
valescence is fully established. 

In unfavorable cases, death may occur rather suddenly in the second 
stage, without any very decided change in the physical signs, from exhaus- 
tion or from the supervention of collapse of portions of the lung-tissue. In 
these cases, the breathing becomes more and more rapid and labored, or it 
becomes slower than before ; the moist rales increase in abundance and 
extent, while the percussion often remains about the same ; the difficulty 
of sucking increases, so that the child, when put to the breast, attempts to 
draw but two or three times and then lets go exhausted and distressed, or 
it makes no efibrt whatever ; the cough becomes less frequent, but is still 
painful and difficult ; the skin grows pale and white, excepting about the 
face, hands, and feet, where it often assumes a bluish or cyanotic hue; the 
extremities, and often the face too, become cool; the child becomes ex- 
ceedingly restless, and then dull and perfectly quiet or comatose, and death 
at last occurs from asphyxia. In another class of cases, which, however, 
are much more rare in very young children than in older ones, the disease 
passes into the third stage, or that of suppuration, so called. In such cases 
the febrile symptoms continue much longer than in those just now de- 
scribed ; the pulse becomes, and continues for several days together, very 



SYMPTOMS. 165 

frequent and jerking; the skin retains its heat and dryness, though it is 
often pale at the same time; the ehikl is usually excessively irritable and 
distressed ; the breathing is rapid and oppressed, and often very irregular 
and uneven ; the dulness on percussion extends ; the bronchial respiration 
becomes more distinct and is heard over larger surfaces, and is accompa- 
nied with less of the subcrepitant and crepitant rfdes ; the cough is parox- 
ysmal, painful, and often very harassing ; the appetite is lost, and the sleep 
uneasy and often broken. These symptoms continue for several days, or 
a week or two, when they assume the same character they exhibit in more 
rapidly tatal examples ; that is to say, asphyctic phenomena develop them- 
selves, and the child dies exhausted and comatose or perhaps convulsed, or 
after presenting for some hours, or a day, more or less severe spasmodic affec- 
tions of different muscles or of the extremities. 

The lobar pneumojiia of children over two years, and especially of those over 
five years of age, exhibits most of the symptoms that characterize the 
game disease in adults. The chief differences to be noticed at these two 
periods of life, are the greater predominance of bronchitis in children, 
particularly in those under five or six years of age, which gives to the 
physical signs some peculiar features not observed in adults ; the frequent 
absence of expectoration, and when it is present, certain differences be- 
tween it and that of adults ; certain peculiarities in the character and 
seat of the side-pain ; and the existence in many instances of more marked 
and more dangerous nervous symptoms. 

The mode of onset is very different in different subjects. Generally, the 
attack begins with violent fever, increased frequency of breathing, more or 
less pain in the side, and short, dry cough. In such cases there is no diffi- 
culty in perceiving that the disease consists of some form of thoracic in- 
flammation. But, in other instances, instead of this open and frank de- 
velopment, the disease comes on with symptoms which might well mislead 
any but a very attentive and competent physician, as to the true nature of 
the case. The most common cause of obscurity is a predominance of the 
nervous symptoms, which often gives to the case very much the aspect of 
a meningeal inflammation. In an example that occurred to one of our- 
selves, a boy between six and seven years old was seized, after a short ex- 
posure during a ride on a raw and cold day, with violent fever, pain in 
both ears, severe frontal headache, and great sensibility to light when ex- 
posed to it. He was, at the same time, very drowsy, sleeping nearly the 
whole day, but he could be roused when loudly and vehemently spoken to 
so as to answer a few questions and manifest great irritability, and, what 
was extremely suspicious of disease of the brain, when taken with the other 
symptoms, he vomited frequently. On the second day, the headache was 
ver}' severe, the .sensibility to light continued excessive, and he still vomited 
frequently, rejecting even water. The bowels were freely moved. There 
was up to this time no full cough, but only an occasional and slight hark- 
ing, that scarcely attracted attention. The respiration was accelerated, 
but there was no dyspnfjea. No pneumonia could be detected, though care- 
fully sought after. On the third day, the breathing was ntill more fre- 
quent, but not at all laborious; the vomiting continued, but the other 



166 PNEUMONIA. 

nervous phenomena had lost some of their intensity, and auscultation re- 
vealed well-marked bronchial respiration before and behind, over the sum- 
mit of the right lung, while over the same regions the percussion was dull. 
We have met with several cases in which the onset of pneumonia was 
attended with nervous symptoms that made the diagnosis difficult and 
obscure. 

In other cases the onset of the disease is marked by symptoms of gastro- 
intestinal irritation, or by such a degree of fever and disturbance of the 
nervous system, with absence of evident local phenomena, as to render the 
nature of the attack obscure and uncertain. In one, for instance, occur- 
ring in a boy between four and five years old, and six weeks after recovery 
from measles, the attack began suddenly with violent fever, great restless- 
ness and distress, vomiting, and distension of the abdomen. The case ap- 
peared to be one of gastro-intestinal disorder, as there was nothing to call 
attention to the thorax. On the second day, the symptoms were much 
worse, the skin being hot and dry, and the pulse one hundred and sixty 
in the minute, and jerking. The child was drowsy and heavy ; it was 
difficult to make him answer questions, and his answers were confused and 
unintelligible ; his movements were tremulous and uncertain. The tongue 
was dryish and very thickly coated, and he complained confusedly of pain 
in the abdomen, which was much distended, and sonorous on percussion. 
There was no sign of respiratory disease, except quickening of the breath- 
ing, and a very slight cough, scarcely to be noticed. At this moment, 
however, when scarlet fever was apprehended from the great frequency of 
the respiration, the drowsiness, and the tremulous character of the muscu- 
lar movements, auscultation and percussion revealed the true nature of the 
sickness in the shape of a lobar pneumonia of the lower lobe of the left 
lung. 

In a majority of the cases, however, instead of the obscure and decep- 
tive onset we have just described, pneumonia begins with fever, acceleration 
of the respiration, pain in the side, and short, dry cough. In some instances 
the disease supervenes upon catarrh or bronchitis. The child ceases to 
play, refuses to be amused, and is either irritable and cross, or lies listlessly 
upon the bed, or, if still quite young, insists upon being kept upon the lap. 
In some few cases, in very young children, convulsions occur. The appe- 
tite is lost, or else very much diminished ; the thirst is acute, and when 
the disease is once established, more urgent than in almost any other affec- 
tion. Vomiting is quite common, especially in young children, but diar- 
rhoea is rare, the bowels being generally more torpid than usual. From 
the first day often, and almost always by the second, we can perceive either 
crepitant or subcrepitant rale, and sometimes bronchial respiration, confined 
usually to one side, and more frequent below than above, though, be it re- 
marked, not at all rare over the latter part. 

As the case proceeds, the fever increases, the bronchial respiration be- 
comes more distinct and is heard over a larger extent of surface, whilst 
the rales diminish in abundance. The skin is now very hot and dry, so 
as to impart a burning sensation to the hand ; the pulse augments in fre- 
quency, seldom counting less than 140 in the minute, often mounting to 



SYMPTOMS. 167 

160, and iu severe cases, and in young children, even to 170, and becoming 
full and hard ; the respiration becomes more and more accelerated, until 
it rise^ to 40 or 50, and in a great many cases to 60, 70, or even 80, while 
it often becomes at the same time oppressed, and, when full inspirations 
are made, painful ; the cough is frequent, dry, or almost dry, and jmiuful 
at first, but after a few days begins to be moist, and, in children over six 
or seven years of age, is not unfrequently attended with an expectoration 
of rusty or sanguinolent sputa ; the thirst continues intense, the appetite 
is null, and the child is very restless and irritable, or drowsy and inatten- 
tive. About the fourth or fifth day, as a general rule, the disease has 
attained its height, the febrile and local symptoms being then most marked, 
and the extent of the inflammation greatest, as shown by the physical 
signs. 

At this stage of the disease, the bronchial respiration is generally strongly 
marked, being clear and distinct, audible both in inspiration and expira- 
tion, and accompanied by bronchophony and increased resonance of the 
cry. The dulness on percussion is also very evident, the change from the 
natural sound being easily perceptible on a comparison of the two sides. 

The symptoms generally remain stationary at this point for one or two 
days, and then begin to subside. The heat of skin diminishes and perspi- 
ration often appears ; the pulse falls in frequency and force ; the respira- 
tion becomes slower, easier, and full inspirations can be taken without pain ; 
the alic nasi no longer 'dilate ; the cough becomes quite loose, and ceases to 
be painful ; the thirst is less acute ; the child loses some of its irritability 
and restlessness, and if it have been soporose and dull, becomes more wakeful 
and observant ; the flushing of the face disappears, while the expression 
is more natural. On auscultation, the bronchial respiration is found to 
have lost some of its intensity ; it has become more distant, or it is heard 
only in the expiration, and is mingled with, or in part replaced by, crepi- 
tant or abundant subcrepitant rales. The dulness on percussion is less 
marked. A little later, the fever ceases entirely, the respiration reassumes 
its natural rate, the appetite returns, the thirst disappears, the cough sub- 
sides very much, and the child begins to be interested in its toys or occu- 
pations. About the tenth or fifteenth day, and in some cases rather earlier, 
convalescence is fairly established, thougli auscultation may still reveal 
some prolongation of the expiatory sound and difl^use resonance of the 
voice. 

In unfavorable cases, death seldom occurs early in the disease, but 
iLsually at some distance of time from the invasion, and in consequence, 
no doubt, of the transition of the inflammation into the third or suppura- 
tive stage. In such ca.ses the disease has usually pursued the course just 
described up to the period of resolution; but, instead of resolution and 
convalescence taking place, the fever continues, though perhaps with di- 
minished violence, the skin being less intensely hot, and the pulse less full 
and active, while it remains quite a.s frequent. The breathing is sometimes 
less frequent than before, but it is often more laborious, and very generally 
it becomes irregular, and is easily hurried under exertion. The cough 
varies very much, beint: HtiiHrtiriic- alino.-t suppressed, and in other cases 



168 PNEUMONIA. 

very troublesome ; it is almost always loose. The strength diminishes, the 
voice becoming weak and feeble, and the muscular movements tremulous 
and languid ; the face looks pale, haggard, and sunken ; the child is some- 
times very restless, tossing about from time to time on the bed or lap, with 
a quick, short, and evidently feeble movement, or it is dull and soporose, 
awakening only when spoken to, but showing then by its fretfulness and 
peevishness that its intelligence is retained. While these symptoms are 
present, the extent over which the bronchial respiration is heard has gen- 
erally augmented, showing the gradual extension of the hepatization, while 
outside of the part where the respiration is blowing, and sometimes over 
the same part, and intermingled with that sound, are heard more or less 
copious subcrepitant and mucous rales. This condition seldom lasts more 
than two or three days, at the end of which time the child dies in a state 
of coma, or after one or more convulsive seizures, which are the result of 
a gradually increasing asphyxia. 

In other cases, again, the termination is more gradual. The child, 
after presenting many of the above symptoms, may seem to improve 
somewhat. The fever may diminish, the appetite return to some extent, 
the respiration become easier, the restlessness subside, and the child be- 
comes more cheerful again ; but the face continues pale, emaciation makes 
progress, the appetite fails again, the pulse remains frequent, diarrhoea 
comes on, the cough becomes more troublesome, thrush often attacks the 
mouth, the strength decays continually, and, after some weeks perhaps of 
struggling, the child dies in a state of great emaciation and debility. 

Catarrhal Forim. — The symptoms of catarrhal pneumonia are much 
more obscure and uncertain than those of the lobar form of the disease. 
Owing to the fact that the inflamed patches of the lung are disseminated or 
scattered through healthy portions of the organ, the signs afforded by 
physical examination are either very imperfect, or entirely masked by the 
sounds produced in the healthy texture. We are forced, therefore, to de- 
pend much more in this than in the lobar form, on the rational symptoms, 
in determining the nature of the sickness. The rational symptoms of 
partial pneumonia are nearly the same as those of the lobar form. The 
chief diflTerences between the two are in regard to the pain, the d3'"spnoea 
and, when there is expectoration, the amount of the sputa. The febrile 
and nervous symptoms, and the disturbances of the digestive system, are 
the same in the two forms, the only diflference being in their degree of 
severity. In the lobar variety they are usually more acute and severe 
than in the partial. The mere degree of temperature attained does not 
differ materially in the two forms, and it is not unusual to find a temper- 
ature of 103° on the second day of an attack of the catarrhal form. 
Roger {loc. cit.) notes, however, that while in lobar pneumonia the high 
temperature is sustained for six or seven days until defervescence occurs, 
iu the catarrhal form the course of the temperature is marked by a suc- 
cession of irregular remissions and exacerbations. The local symptoms 
present important differences which should be noted. In the form under 
consideration, the pain is either wanting entirely, or is much less acute 
than in the lobar form. When the inflamed patches are few in number, 



I 



SYMPTOMS OF THE CATARRHAL FORM. 169 

and they are seated in the central parts of the liinc:, there is entire ab- 
sence of pain ; but when they are more numerous and superficial, j^ain is 
complained of, but it is usually diffuse, of slight intensity, changeable, 
and felt only during cough, or during full inspirations. It makes its ap- 
pearance commonly on the first day, and very seldom after the third. 
Cough is rarely wanting. It usually marks the onset of the sickness, is 
extremely variable as to its frequency and severity, and is not acutely 
painful, a^ in the lobar form, unless the inflamed patches be superficial. 
There is seldom any considerable amount of expectoration, and in some 
cases none : when there is any it is small in quantity, and it may or may 
not be characteristic. In one case, however, that came under our obser- 
vation, in which we had every reason to believe, from the nature of the 
rational symptoms, and from the absence of physical signs, that the dis- 
ea$^ was catarrhal pneumonia, there was a rare expectoration of thick, 
viscous mucus, streaked with blood. The respiration is accelerated, and 
when the lesion is at all extensive, there is dyspnoea, the degree of these 
symptoms being determined by the extent and number of the inflamed 
patches. 

The physical signs are not, as above stated, very significant. The per- 
cussion is natural, the amount of tissue consolidated being insuflicient to 
aflTect the sonorousness of the chest. According to Eustace Smith, a gene- 
ral want of healthy pulmonary resonance can be detected over the back 
by means of broad percussion, striking with three fingers upon three 
fingers placed on the chest-wall as pleximeters. Auscultation affords no 
signs of the pneumonic inflammation when the number of aflfected patches 
is small ; when they are more numerous it is of some, but not of very 
great utility. Crepitant rale is sometimes heard here and there over cir- 
cumscribed points of the thorax, and, disseminated in the same way, there 
is also heard in some instances rude respiration, prolonged expiratory 
murmur, and bronchial respiration. When, as often happens, this form 
of the disease coexists with bronchitis, it will be entirely concealed by the 
dry and moist rales of the latter aflfection. If a number of aflfected lob- 
ules coalesce and form a superficial patch of some size, we may have dis- 
tinct signs of consolidation over a circumscribed area. This is, however, 
rare. 

The duration of lobar pneumonia has been fixed with considerable ac- 
curacy by the observations of various persons. As a general rule, the 
disease reaches its highest point of severity in about four or five days, 
then remains stationary for one or two days, and diminishes regularly 
until between the tenth and fifteenth day, when convalescence is estab- 
lished. Id our own practice, the longest duration in 22 unmixed cases, in 
which the period was accurately noted, was 17 days, and the shortest 5. 
The duration of the 22 cases was as follows : in 1 case, 17 days ; in 2 cases, 
14 days; in 1, 11 ; in 4, 10; in o, 9 ; in 3, 8 ; in 2, 7 ; in 2, 6 ; and in 2, 
5 days. One case lasted 33 days, but it was accompanied and followed 
by bronchitis. 

It is difficult to assign any definite duration for the catarrhal ff)rm. In 
favorable cases, judicious treatment will often be followed by convalea- 



170 PNEUMONIA. 

cence in from a week to ten days. But in many instances the symptoms 
persist longer than this ; and not unfrequently the case shows a strong 
tendency to pass into a chronic form. 

Particular Symptoms ; Physical Signs. — In order to practice aus- 
cultation and percussion in a young child, it should be placed, by the 
mother, in a sitting posture on her knee, while the physician, kneeling on 
the floor, or sitting on a low chair, makes the examination he deems neces- 
sary. If the child be old enough to take notice, it should be attracted and 
amused by some toy or glittering object. Even, however, should it cry 
violently, much valuable information is to be obtained by the examina- 
tion, for we can ascertain the presence or absence of rales and their char- 
acters during the deep inspirations between the cries, and can observe res- 
onance of the cry and cough, and practice percussion. 

The physical signs of lobar pneumonia are crepitant or subcrepitant 
rale, feeble respiratory murmur, bronchial respiration, bronchophony, ex- 
aggerated resonance of the cry and cough, and dulness on percussion. 
They are, in fact, the same in the great majority of cases as in adults. 
Under five years of age, this form often begins with subcrepitant rale, 
while after that period the earliest stethoscopic signs are crepitant rale, or 
feeble respiration. The bronchial respiration makes its appearance soon 
after the subcrepitant or crepitant rale, is heard first in the expiration, and 
then in both inspiration and expiration, and is accompanied by bronchoph- 
ony, resonance of the cry and cough, and dulness on percussion. Bron- 
chial respiration was present in 46 of the 57 cases of lobar pneumonia 
observed by ourselves ; crepitant rale was present in 31, and subcrepitant 
in 10. 

These alterations of the auscultatory phenomena are confined to one side, 
in the great majority of cases, and are best observed over the postero-in- 
ferior portion of the lung. MM. Pilliet and Barthez state that they have 
never known the bronchial respiration to disappear, in favorable cases, be- 
fore the fifth day, and in the majority not before the seventh, eighth, or 
ninth ; while, in fatal cases, it continued to the moment of death. Its per- 
sistence is always a highly unfavorable symptom in very young children, 
whilst in those who are older, as in adults, it sometimes remains for several 
days or weeks, though the general symptoms have entirely disappeared. 
In catarrhal pneumonia on the other hand, as we have already stated, the 
physical signs are often present on both sides, and are much less definite. 

Eational Symptoms. — Cough may be said to be invariably present. 
It is dry at first, and not very frequent, but in one or two days becomes 
more frequent, often very troublesome, and from dry and harsh, becomes 
more or less humid and loose. It continues until the disease moderates, 
lasting generally from nine to sixteen days. In fatal cases it usually 
persists to the last. In infants it is not very frequent, occurs in short 
paroxysms, and in fatal cases often ceases one or two days before death. 
MM. Rilliet and Barthez remark that in pneumonia of the upper lobes, 
it has a peculiar character. It is little, short, smothered, as it were ; or 
piercing, teasing, or slightly hoarse. We will merely add that cough 
is sometimes scarcely noticeable in cases which simulate hydrocephalus, 



I 



RATIONAL SYMPTOMS. 171 

during the early part of the attack. In a case already referred to, that 
occurred to one of ourselves, in which the symptoms bore for several days 
very much the aspect of a meningeal attack, there was no full cough what- 
ever during the first two days ; on the third day, though auscultation and 
percussion showed the existence of pneumonia of the upper lobe of the right 
lung, the child coughed only three or four times, and it was u'^»t until the 
sixth day that it became at all frequent. In three other cases the cough 
wa^ so slight in the early stages of the disease, during the continuance of 
the cerebral symptoms, as not to have been noticed unless particularly in- 
quired after. Later in the attack, after three, four, or five days, and as the 
cerebral symptoms moderated, the cough became frequent and loose, and 
the pneumonic symptoms pursued their regular course. 

Expectoration is almost invariably absent under five yeai*s of age. MM. 
Rilliet and Barthez, and Dr. Gerhard, have never observed rust-colored 
sputa under the age mentioned. In older children there is sometimes, 
though not very often, voluntary expectoration. Even in them, however, 
the sputa seldom present the characteristic rust-color and viscidity ob- 
served in adults, but consist simply of mucus tinged with blood, or of 
whitish, brownish, viscous, or non-viscous phlegm. We once, however, 
saw a child three and a half years old, voluntarily expectorate viscid 
mucus, tinged copiously with blood. Sanguinolent expectoration was no- 
ticed in five of the fifty-seven cases seen by ourselves (not including the 
one just spoken of). In three the sputa were of the characteristic rusty 
color, in one they were composed of mucus streaked with blood, and in 
another portions of mucus streaked with blood were rejected by coughing, 
and some also by vomiting. The age of the five subjects, just alluded to, 
was in each case between five and nine years. In another case (not in- 
cluded amongst the five), in a girl seven years old, affected with lobar 
pneumonia supervening upon pertussis, there was a free expectoration of 
tenacious mucus, sometimes streaked or dotted with blood, sometimes 
brownish, and sometimes rust-colored. 

M. Valleix mentions a whitish or sanguinolent viscous froth, as some- 
times escaping from the mouth of new-born children laboring under the 
di.sea5e, and Bouchut has also noticed in a single case, a little reddish 
sanguinolent froth, situated on the edge of the lips of an infant with pneu- 
monia. We have never met with this symptom, but know of one case of 
a child within the month, who, during an attack of pneumonia, vomited 
mucus tinged with blood. The child died, and presented the lesions of 
pneumonia. The nipples of the mother were perfectly healthy, so that 
the blood couhl not have been sucked by the child from them, but must 
have consisted of the sputa which had been swallowed after being coughed 
into the fauces. 

It is scarcely neces-sar)' to .say that the absence of expectoration is only 
.<»eeming, for children undoubtedly cough the sputa into the fauces, whence, 
instead of being rejected, as by the adult, they pa.ss into the stomach. 

Thftrcicic Pain. — It is impossible to ascertain the presence of this symp- 
tom with positive certainty prior to the age at which children talk, and 
very often not for some time after, as they refuse or do not know how to de- 



172 PNEUMONIA. 

scribe their sensations. And yet, even in infants, the presence or absence 
of the stitch in breathing, and of pain in coughing, may be inferred, almost 
with certainty, by watching the gestures and expression of the child, and 
the cries which accompany a full inspiration and the act of coughing. In 
effect, the deep inspirations induced by moving the child, those which take 
place during vomiting and gaping, and those also which occur in the act 
of coughing, cause the child to cry out suddenly and sharply, and give at 
the same moment an expression of acute suffering to the countenance, 
which can be referred to nothing else than the causes just mentioned, 
and which reveals almost as plainly as words the pain fulness of a deep in- 
halation and of the act of coughing. In older children, we have several 
times known the pain to be most intense, causing bitter and repeated com- 
plaints, with crying, fretting, and evident acute suffering. The seat of 
pain, as complained of by children who talk, ought also to be noticed, 
since the account given by them might v/ell mislead an unwary and in- 
experienced physician. It is quite common, in fact, for them to refer the 
pain to the false ribs, to one of the flanks, to the abdomen, and even to 
the hip. 

The respiration is always quickened, except where the constitution of 
the patient has been greatly deteriorated by long and severe illness or 
other causes, under which circumstances it may remain at the normal rate, 
or be very slightly accelerated. This symptom usually dates from the in- 
vasion, soon after which the breathing rises as high as 40, 50, and 60 in 
the minute in older children, and from 60 to 80 in the younger. It some- 
times becomes excessively rapid, reaching, as it did in a case of pleuro- 
pneumonia in an infant six weeks old under our charge, 128.. In favor- 
able cases, the acceleration subsides usually about the seventh, eighth, or 
ninth day. In most of the cases the breathing is even and regular, while 
in others it is short, abdominal, uneven, and jerking. When the dyspnoea 
is very great in a young child, the nostrils dilate widely, the mouth remains 
open, and its angles are drawn downwards and outwards; the last of these 
symptoms is almost a fatal one. Sometimes the rhythm of the function 
is changed, so that it begins with a sudden, active, and moaning expiration, 
followed by the inspiration, after which comes the interval of rest. MM. 
Rilliet and Barthez state that unequal, jerking respiration, occurs almost 
exclusively in cases of inflammation of the upper lobes. 

Physiognomy. — The face is almost invariably flushed. The color, at 
first scarlet, becomes after a day or two deeper and darker, and in severe 
cases assumes a livid-red tint. We have noticed in very severe pneumonia, 
in addition to the deep-red tint, a peculiar glazed appearance of the skin, 
which looks as though it had been varnished, while the edges of the flush 
are distinct and abrupt. The lips are generally deeply colored, simultane- 
ously with the face. The flush commonly subsides about the same time, 
or a little before the diminution in the rate of the respiration. In fatal 
cases, the face is apt to lose its color, and become pale and sallow, as the 
unfavorable symptoms become more and more marked. The pallor of the 
face is most striking in severe and fatal cases occurring in infants ; the face 
is blanched and the features pinched. 



RATIONAL SYMPTOMS. 173 

The expression of the face is one of anxiety and oppression in the early- 
stage ; in very severe cases, or those about to terminate unfuvorably, the 
features become drawn and contracted. 

Fever exists in all the idiopathic cases. The pulse, at all ages, is rarely 
under 130 from the first to the sixth or seventh day ; in the youngest chil- 
dren it rises as high as 140, 160, and even 180; while in those wlio are 
older, it is seldom above 140. In favorable cases, it diminishes about the 
fifth, sixth, or seventh day. In fatal cases, it is apt to diminish at the 
same period, but soon becomes more frequent and continues so to the end. 

The range of temperature in pneumonia is higher than in any other in- 
flammatory disease of children. This is true of the disease in both of its 
forms — lobar and catarrhal. The highest temperature we have found re- 
corded for pneumonia is 105.8^, which Roger, in his latest contribution to 
this subject {Becherche^ Cliniques sur les Mai, de VEnfance, 1872, p. 356), 
states was observed by him in 2 out of 47 cases of pneumonia. In two- 
thirds of the entire number tlie mercury reached or exceeded 104° ; and 
the mean of the highest temperatures in all the cases was 103.9°. Such 
high degrees are more apt to be found in children over than under 2 years 
of age. The maximum temperature reached in any case would not seem 
to be much influenced by the seat or extent of the inflammation. 

In lobar pneumonia the course of the temperature is regular and char- 
acteristic. The accession of fever is often very sudden, and the mercury 
may rapidly rise to its maximum point, marking 104°, 105°, or even 
105.8°, within twelve hours from the onset. After the first abrupt rise, it 
is sustained nearly at the same point, with moderate morning, remissions 
and evening exacerbations (the variation usually not exceeding one or one 
and a half degree) until defervescence, which is usually rapid, or even 
abrupt, occurs. In the catarrhal form, on the other hand, the initial rise 
of temperature is less abrupt, and the course of the fever is marked by the 
occurrence of irregular remissions and exacerbations, which Roger attrib- 
utes to the development of successive patches of pneumonia. 

The ratio between the temperature, pulse, and respiration may be quite 
closely preserved, and the elevated degree of febrile heat be associated 
with marked acceleration of the pulse and breathing. Thus Roger found 
that the mean furnished by 47 cases was : temperature, 103.04° ; pulse, 
133 ; respiration, 52. It is not, however, at all rare in both forms of the 
disease for the pulse-respiration ratio to vary from the normal 1 to 4 to 
1 to 2, or even 1 to 1.5. In the lobar form, it will frequently be found that, 
following the defervescence, the temperature falls below the normal point, 
as to 98° or 97°, for a day or two. 

The nervous syatem shows more or less marked symptoms of disorder. 
There is restlessness, peevishness, and irritability during the day, and these 
increase towards evening. As the night advances, the child l)ecomcs still 
more restless; infants will not sleep except in the arms, and wake crying 
or fretting ever}' few minutes or hours ; older children sleep unea.-?ily, talk 
in their sleep, or start and cry out, and are often delirious. In some in- 
stances, the irritability is most distressing, both U) the child and to those 
around. The child is eonsUntly fretting and whining ; it wants it^ play- 



174 PNEUMONIA. 

things, but will not touch them ; food, but rejects it ; and slaps and scolds 
at everything about it. Convulsions sometimes occur at the invasion. 
They last an uncertain length of time, and are usually followed by insen- 
sibility, from which the child wakes with fever, accelerated respiration and 
cough, indicating the true seat of disease to be the lungs, and not the 
brain, as might at first be supposed. We have met with but three cases, 
all of the lobar form, attended with convulsions. One occurred in a boy 
between ten and eleven years of age, on the second day of the disease. 
The attack was induced more, however, by an unwholesome meal taken on 
the first day of his sickness, than by the mere effect of the local inflamma- 
tion. In a second case, which occurred in a boy between five and six years 
old, there were two convulsive seizures, a violent one on the first day of the 
pneumonia, and a slighter one a few days later. In the third case, which 
occurred in a boy aged two years, the pneumonia occurred in the course of 
intermittent fever; there were three marked convulsions, but the child sub- 
sequently recovered perfectly. The headache is sometimes very severe ; in 
a few instances we have known it to be so violent as to constitute the most 
prominent symptom of the case. On one occasion, indeed, it was so in- 
tense, and so much complained of, during the first two days of the fever, 
as to withdraw our attention from the true seat of disease, and it was not 
until the third day that we discovered the existence of pneumonia. The 
cough was in this, as in other instances, in which the nervous symptoms 
were strongly marked, so slight as to escape notice. 

Digestive Orga7is. — Complete anorexia is generally present from the 
first ; the thirst is intense, greater indeed than in almost any other affec- 
tion of childhood. The tongue is moist, as a general rule, and covered 
with a whitish or yellowish fur. Vomiting and diarrhoea occur at the 
invasion of about half the cases in hospitals ; in private practice, vomit- 
ing often occurs, but diarrhoea much less frequently. 

Urine. — The amount of uriiie is materially lessened in acute lobar 
pneumonia, the extent of the reduction being from one-third to one-half 
(Parkes). 

During the height of the disease the urea is increased, and with it, as 
in most febrile diseases, the uric acid. Simon and Redtenbacher first 
called attention to the fact that the chloride of sodium is diminished or 
entirely absent during the early period and at the commencement of he- 
patization, and reappears during, or rather after resolution ; and further 
researches have fully confirmed this observation, since very few excep- 
tional cases have yet been recorded. The disappearance does not depend 
upon the reduced diet, since Howitz and Parkes both state that even when 
chloride of sodium is administered, none can be detected subsequently in 
the urine. And the fact that it is in reality retained in the system, is fur- 
ther shown by the very excessive excretion during convalescence. Ac- 
cording to Beale's observations, the exudation in the lung is very rich in 
chloride of sodium; and it has been found that as this salt disappears from 
the urine, it appears in the sputa, and in turn as it returns in the urine, it 
disappears from the sputa. 

It is true that more extended observation has shown that the chloride of 



DIAGNOSIS. 175 

sodium is absent or deficient in many other affections, both febrile and in- 
flammatory; but still, although not pathognomonic of pneumonia, this 
sign is an aid in its diagnosis, and probably serves to distinguish it tVoni 
collapse of the lung or tuberculous consolidation. 

One more condition of the urine in pneumonia, although as yet, so far 
as we know, only noticed in adults, deserves attention. We allude to the 
presence of albumen, which has been noticed by several observers, as 
Finger, Becquerel, Parkes, and Heller, in almost 45 per cent, of their 
cases ; though others have but rarely found it. 

The period of its occurrence is variable; according to Heller and Parkes, 
it appears at the time when the chlorides are most deficient, as hepatiza- 
tion advances. The fatality is much increased in cases where albuminuria 
is present ; the combined record of the observers above referred to, yield- 
ing a mortality of almost 50 per cent, of such cases ; whilst the mortality 
in cases without albuminous urine was only 14 per cent. According to 
Parkes, renal cylinders are very common in the albuminous urine of pneu- 
monia ; and a little blood is also frequently present, but is usually out of 
all proportion to the albumen. 

Diagnosis. — The lobar pneumonia of children is most liable to be con- 
founded with bronchitis, pleurisy, and meningitis. There is little prob- 
ability, however, that lobar pneumonia would be mistaken for bronchitis 
by any but a careless or incompetent observer ; for the presence, in the 
former, of subcrepitant, and very often of crepitant nlles, of bronchial 
respiration, bronchophony, resonance of the cry and cough, and dull or 
flat percussion, confined to one side, would easily distinguish it from bron- 
chitis, which is marked by dry and moist rales over both sides of the 
chest, and by a normal condition of the percussion. It is difficult and 
often impossible, as already stated, to detect the existence of catarrhal 
pneumonia, or at least to make the diagnosis with absolute certainty. 
The cause of the difliculty, as before explained, lies in the fact that it 
presents, in a great many instances, no clear physical signs. When the 
number of inflamed nodules scattered through the healthy texture of the 
lung is small, and especially when they are deeply seated, no alteration 
whatever of the natural respiratory sounds can be perceived, and we are 
obliged to depend entirely upon the rational symptoms, — the accelerated 
breathing, oppression, pain, cough, fever, and the absence of the physical 
signs of other pulmonary inflammation. A careful study of the temper- 
ature may here be of service. We have seen that in pneumonia the tem- 
perature usually rises quickly to 104° or 105°, while in bronchitis, it 
rarely attains even the lower of these, and often does not exceed lOP or 
102^. Sometimes the presence of the characteristic sputa of pneumonia 
will, in older children, make the diagnosis clear. When the inflamed 
nodules are situated near the surface of the lung, we may, in some in- 
stances, detect crepitant or fine &ubcrepitant rale, and bronchial nsi)ira- 
tion, over circumscribed portions of the lung, and there would be, under 
such circumstances, no hesitation as to the diagnosis. 

It has been stated that pneumonia might be confounded with pleurisy. 
This could not happen in regard to the catarrhal form, as the slighter de- 



176 PNEUMONIA. 

gree of the pain, the limited extent of the rales and bronchial respiration, 
and the absence of dulness on percussion in the latter, would prevent such 
a mistake. The distinction between pleurisy and the lobar form is more 
difficult, but may generally be made out by attention to the fact that pleu- 
risy is rare under six years of age ; by tfie greater severity of the pain, the 
less abrupt and extreme elevation of temperature, the absence of rales and 
presence of friction-sound, the effect of change of position on the sounds 
yielded by percussion, the shorter duration and greater mildness of the 
general symptoms, the entire absence or small amount of expectoration, 
and by the continued dryness of the cough in pleurisy ; and lastly, by the 
disposition on the part of pleurisy to become chronic, while lobar pneumo- 
nia nearly always runs an acute course. 

Lobar pneumonia in children not unfrequently simulates, in its early 
stage, an attack of meningitis, constituting a form of the disease some- 
times called cerebral pneumonia. Vomiting, constipation, extreme irrita- 
bility or restlessness, and complaints of headache, occur in both ; while 
the absence of thoracic symptoms to draw attention to the true seat of the 
disease in pneumonia, may readily mislead. The cough in the early stage 
of pneumonia is sometimes very slight, and not being observed by the 
attendants, is not reported to the physician. The frequency of the respi- 
ration is overlooked, or, if noticed, it ascribed to the fever, which is sup- 
posed to depend on the cerebral inflammation. In pneumonia, however, 
the vomiting is not usually very frequent, nor very obstinate, nor are the 
bowels so much constipated as in acute hydrocephalus. These variations 
from the ordinary symptoms of the latter disease, minute though they be, 
ought to attract the notice of the physician, and lead him to examine the 
case more carefully, when, in all probability, the physical signs would 
immediately reveal the pneumonia. We may mention, in illustration, that 
we attended a boy six years old, who, for three days, suffered from violent 
fever and excruciating headache, which last was the only symptom com- 
plained of. There was neither cough, expectoration, nor any marked 
acceleration of the respiration. After three days the headache moderated, 
and he had slight pain in his side ; on examination, we found him laboring 
under well-marked lobar pneumonia. In April, 1847, one of us was called 
to see a boy nineteen months old, who had been taken sick with slight 
fever, a little hoarse cough, and mild pharyngitis. After remaining in 
this condition for five days, he began to be drowsy and very irritable, the 
surface became pale, and the extremities rather cooler than natural. 
From the sixth to the tenth day there was great somnolence, the child 
sleeping nearly all the time; when waked from sleep, he was always ex- 
ceedingly irritable and cross, scarcely opening his eyes, and then shutting 
them again immediately to avoid the light, which was evidently painful. 
During this time he took scarcely any food, but little drink, and vomited 
several times freely ; the bowels were moved without medicine ; the surface 
remained very pale, and the extremities often cool ; the pulse was frequent 
and small, the respiration perfectly regular, for which reason it attracted 
no attention, and there was no cough whatever. Under these circumstances, 
we hesitated between regarding the case as one of meningitis, or of hydro- 



DIAGNOSIS. 177 

cephaloid disease, as described by Dr. M. Hall. We took the latter view, 
however, and treated it with small quantities of brandy, cold to the head, 
and the frequent employment of mustard pediluvia. From the eleventh 
day the child began to improve; it would open its eyes from time to time, 
and look round for a few moments ; the face began to show a slight degree 
of color, and the palms of the hands, which had been white and trans- 
parent, exhibited a tinge of the natural pink hue which they have in 
children. Observing about this time that the respiration was accelerated, 
though perfectly free and regular, and without cough, we counted it, and 
were astonished to find it 80 in the minute. We now examined the chest 
carefully, and finding slight dulness on percussion with bronchial respira- 
tion, over the inferior half of the left side behind, immediately understood 
the nature of the case: it was one of latent pneumonia, simulating hydro- 
cephalus. The child was now treated for pneumonia, and after an illness 
of twenty-seven days longer, recovered perfectly. As the case progressed, 
the rational signs of pneumonia were more and more apparent, the cough 
becoming frequent and painful, and after a time loose, while the cerebral 
symptoms gradually disappeared. 

In addition to these cases, we have met with several others which during 
the early stage resembled very closely the invasion of cerebral disease. 
One of these has already been referred to in the account of the symptoms 
of the disease. Two others occurred in children within the year, and one 
in a child between one and two years old. Attention, however, to the rate 
of the respiration and the physical signs, and the presence of slight cough, 
revealed, iu two of them, after a little hesitation, the true character of the 
attacks. The third case, which occurred in one of the children within the 
year, was unattended by any cough during the first few days, and was, 
therefore, very obscure, until our attention was attracted by an accelera- 
tion of the respiration, when the physical signs, and, at a later period, the 
cough, explained the real nature of the attack. We may remark, in ad- 
dition, that in all these cases, the absence of constipation, the infrequency 
and short duration of the vomiting, and some clearness of the intelligence 
when the child was fairly roused, though but for a few moments, from its 
state of somnolence, were other motives for doubting the attacks to be 
meningitis. 

We have dwelt at length upon the danger of making this serious mis- 
take in diagnosis, in the hope that our remarks will aid in impressing 
upon the naind of our readers the great importance, which has indeed i)een 
alluded to on several previous occasions, of making a careful examination 
of the chest by auscultation and percussion in every case of acute discijise 
in children, even though the symptoms do not appear to indicate any 
affection of the heart or lungs. 

Dr. West states that pneumonia is often overlooked in teething children, 
in whom the cough is called a tooth-cough, whilst the diarrlnra, which 
frequently occurs, and becomes the prominent symptom, is suppohcd to 
depend upon dentition, and is alone attended to. The diarrhu'a is obsti- 
nate, and when, at last, the cough attracts attention, it is ascribed to 
phthisis, and the physician in astonished to find at the autopsy purulent 

12 



178 PNEUMONIA. 

infiltration of the lungs, but no tubercles, and no disease of the intestines. 
The diagnosis is to be correctly made, under such circumstances, only by 
careful physical examination. 

The disease with which catarrhal pneumonia is most apt to be con- 
founded is bronchitis. The two are frequently associated, and, owing to the 
fact that the physical signs of consolidation of lung-tissues cannot always 
be detected in the catarrhal form, our diagnosis must sometimes be based 
solely upon the general symptoms. If we find, however, that with or with- 
out previously-existing bronchitis the cough has suddenly assumed the 
pneumonic character, the temperature rapidly risen, and the degree of dysp- 
noea suddenly increased, there is strong reason to believe in the superven- 
tion of catarrhal pneumonia. If we find, in addition to this, impaired res- 
onance at various points, with imperfect bronchial breathing and perhaps 
subcrepitant rale at these spots, our diagnosis would be confirmed. We 
must also bear in mind the resemblance which exists between catarrhal 
pneumonia and lobular collapse of the lung. The points of resemblance 
and the fact that both are apt to appear during the course of a bronchitis 
have already been alluded to. In lobular collapse, however, although the 
dyspnoea may be extreme, the symptoms do not indicate any increase in 
the inflammatory action, but, on the other hand, the temperature is nor- 
mal, or even lower than natural. 

Prognosis. — It may be stated in general terms that lobar pneumonia 
is the more dangerous in proportion as the child in whom it occurs is 
younger ; and that the secondary, consecutive, or intercurrent form of the 
disease is much more dangerous than the primary. It is usually supposed 
to be almost necessarily fatal in newborn children, and to be still very dan- 
gerous up to the sixth year of age. There has been so much confusion, 
however, in regard to atelectasis of the lung and true pneumonia until 
within a few years past, that it is scarcely possible to trust to former sta- 
tistics upon this point. From six years of age up to fifteen, the disease is 
generally curable when of the primary form ; when of the secondary 
form the result is much more doubtful, and will depend in great measure, 
of course, on the nature of the disorder during or after which it occurs. 

MM. Killiet and Barthez {loc. cU., p. 535) state that they lost about one- 
eighth of their cases in private practice. Of these, the youngest was a 
year old, the oldest, three years old. To quote their own words: "Some 
evidently died of accidents caused by the medication (poisoning by tartar 
emetic) ; one was the victim of a relapse, due to faulty hygienic care ; and 
others died of cerebral pneumonia of the upper lobe ; they were under- 
going the process of dentition." In the hospital, they lost a seventh of 
their patients. The subjects under five years of age died of cerebral, gan- 
grenous, or intestinal complications. Those over five years of age died, 
some because they were scrofulous or feeble, the inflammation though 
lobar, being double ; and the others, in consequence of the inflammation 
having become complicated with pleurisy, scarlet fever, or meningitis. 
They add, that in the hospital, six-sevenths of the patients attacked with 
secondary pneumonia died. 

In 1862, however, Barthez stated, in a memoir to the French Academy 



PROGNOSIS — TREATMENT. 179 

(Med. Times and Gaz., May lOtli, 1862), that during tlio previous seven 
years, having abandoned the use of depletion in the pneumonia of chil- 
dren, he had treated 212 cases, with a loss of but 2 patients. 

The results of our experience, which, it ought to be remarked, has been 
acquired chietly in private practice amongst the easy classes of society, 
have been as follows: Of 6o cases of well-marked lobar pneumonia, only 
2 were fatal. Of these two, cue occurred iu an infant six weeks old, and 
was accompanied with extensive and violent pleurisy, and the other 
occurred in a child between two and three years old, lasted thirty-three 
days, and was attended with considerable brouchitic inflammation. 

I addition to these, we have seen a certain number of cases which are 
not included in the statistics of our own experience, since some of them 
were only seen, and, perhaps, but a single time, in consultation, while 
others occurred among the children in the large public institutions of this 
city. A far larger proportion of these latter cases proved fatal. 

We may conclude, therefore, that pneumonia under two years of age is 
always dangerous, and much more so when secondary than when primary ; 
that primary pneumonia, between the ages of two and five years, will, if 
treated judiciously, terminate favorably in the great majority of cases in 
private practice; and that when the disease attacks children between six 
and fifteen veal's of age, the termination is nearly always in health. 

The following are some of the most unfavorable symptoms of the dis- 
ease : convulsions ; small, weak pulse ; extreme rapidity of the respiration ; 
persistence of the bronchial respiration in young children ; incomplete 
resolution of the disease within the ordinary period ; excessive and obsti- 
nate diarrhoea; severe cerebral symptoms; great emaciation; greatly 
altered physiognomy ; excessive irritability ; and a yellowish tint of the 
skin. M. Trousseau regards as an unfavorable symptom the occurrence 
of swelling of the veins of the hands, which he supposes to depend on an 
obstacle to the function of haimatosis. 

The prognosis in catarrhal pneumonia is much more grave than might 
be supposed. Supervening, a-s it so frequently does, in very young chil- 
dren already exhausted by a previous attack of bronchitis, there is danger 
that the violence of the attack may cause it to prove fatal in the acute 
stage. The symptoms which would indicate great danger are high tem- 
perature, greatly altered pulse- respiration ratio, with extreme frequency 
of breathing, lividity efface, and the evidences of serious interference with 
aeration of the blood. 

When the attack is less violent, the chances for future recovery are 
naturally much greater; but, it must be remembered that this form of 
pneumonia frequently runs on into a chronic stage and, by the persistence 
of the changes in the alveolar walls, and the cheesy m(;tanH)rph(»sis of the 
accumulated epithelial cells in the alveoli, leads to the dcvel()])ment of 
chronic pulmonary phthisis. The prognosis therefore should always be a 
guarded one. 

Treatment. — When one of the former editions of this work was pub- 
lished, a great change had begun to take place in medical opinion as to 
the proper treatment of di.'sea.se, and especially of acute disease. In that 



180 PNEUMONIA. 

edition this change of opinion was referred to, and its effect upon our own 
convictions and methods of procedure freely acknowledged. Since that 
period this revolution, as it might be called, has continued to make prog- 
ress, until, at the present moment, no one can candidly express his own 
views without referring to it. In view of these facts, we shall not hesitate 
to write at some length on the treatment of pneumonia, in order that our 
readers, and especially the younger members of the profession, may be 
able to comprehend not only the changes that have taken place, but some 
of their causes. 

There is another consideration which has been forced upon us by time 
and experience, which makes us unwilling to dismiss the treatment of so 
important a disease in a few words, and this is, that the method of cure to 
be followed in individual cases must be determined not alone by the simple 
fact that the patient has an inflammatory exudation in the lung-tissue, 
but, in large measure, by the state of the general vitality of the subject. 
What folly, for instance, to suppose that we can safely apply the same 
therapeutic measures to a case of pneumonia in a child just issuing out of 
severe measles, to one in the midst of a dangerous typhoid fever, to a third 
in the spasms of hooping-cough, or to a fourth who was yesterday in con- 
summate health, with every function, up to the moment of the attack, in 
the finest possible working order. To be sure, this is putting the case in 
very strong terms, but they are not too decided to make our meaning 
clear. 

Moreover, we think there is a tendency, in some of the later works on 
diseases of children, and in some, too, of the general treatises on the prac- 
tice of medicine, to lengthened scientific descriptions of anatomical changes, 
symptoms, diagnosis, etc., and to a corresponding diminution of the space 
devoted to therapeutics. This error, as we think it (not to be wondered 
at, perhaps, when we consider the relative difficulty of writing on these 
different subjects), we desire to avoid, and, indeed, we have found it im- 
possible to state our opinions on the subject except at some length. 

Bloodletting. — Twenty years ago depletion formed an almost inevitable 
item in the treatment of pneumonia, but, within the last eight or ten years, 
the views of most observers have undergone a more or less radical change 
in regard to its utility and necessity. Some have abandoned it altogether ; 
others employ it still to a moderate extent. In order that the younger 
practitioner may see the changes which have taken place in this respect, 
we shall quote the views of some of the more important authorities, and 
then give our own. 

Dr. Charles West (4th Am. ed., from 5th English ed., page 285) writes 
as follows : " I cannot forget the good results which I saw years ago from 
the abstraction of blood at the outset of an attack of pneumonia in pre- 
viously healthy children." He, however, does not advise depletion when 
small crepitation has become generally diff*used, still less when dulness or 
bronchial breathing is perceptible. He gives no statistics as to his own 
results whatever. Dr. J. Lewis Smith, of New York, in his work, does 
not even mention bloodletting. Dr. Eustace Smith {Medical Times and 
Gazette^ May 3d, 1873, page 460) says he has never drawn blood from a 



TREATMENT — BLOODLETTING. 181 

child suffering from pneumonia, and that he ha?; never met with a case in 
which such a method of treatment has appeared to liiiu to be in tiie slij^ht- 
est degree desirable. Dr. Thomas Hillier, of London, says of bloodletting 
that it " is now for the most part discarded. I have never had occasion 
to resort to it." He says further, however, that cases miiiht occur where 
it would be proper to recommend it. Such conditions would be, the second 
day of the disease, a large extent of inflammation of the lung-tissue, full 
and bounding pulse, great pain and dyspneva, and a temperature of 105° or 
more. If these conditions existed in a previously healthy child, he would 
think it wise to take a few ounces of blood from the arm. We have already 
referred to the communication from M. Barthez to the Academy of j\Iedi- 
cine of Paris, in April, 1862, intended to vindicate the expectant treat- 
ment of pneumonia in early life. In this paper it is stated that of 212 
cases of lobar pneumonia, occurring between the ages of two and fifteen, 
in the course of seven years, at the Hopital Ste. Eugenie, only 2 had a 
fatal termination, although no approach to active treatment was adopted 
in more than a sixth of the number. Dr. J. Hughes Bennett gives, in 
The Practitioner, for May, 1869, the results of the restorative treatment of 
pneumonia in 153 cases. Of these, 129 were simple and 24 complicated 
cases. Of the 129 simple or uncomplicated cases, of which 35 were double, 
all recovered. Among the 24 complicated cases there were 5 deaths, 
making of the whole number a mortality of 1 in 30f cases. Dr. Ben- 
nett's ca.<es all occurred in adults, but the results are useful to us as show- 
ing the effects of this kind of treatment. 

In a former edition of this work it was stated that one of us had treated 
50 cases of well-marked lobar pneumonia, with two deaths, in private prac- 
tice. Full notes of only 46 of these cases were kept. Of the 46 cases, 39 
were primary or uncomplicated, and 7 secondary or complicated. The 2 
tatal cases occurred, one at six weeks old, and this was attended w'ith very 
-evere pleuritic inflammation, and the other between two and three years 
old ; the latter case lasted 33 days, and was attended with consideral)le 
bronchitic inflammation. Depletion was employed in 16 of the 39 j)ri- 
mary, and in 2 of the 7 secondary cases. It is proper to state that deple- 
tion was not employed in either of the fatal cases. 

How difficult is the task of estimating the comparative value of differ- 
ent plans of treatment in any given disease. MM. Rilliet and Barthez 
hist one-eighth of their ca.ses of pneumonia in private practice, and one- 
seventh in hospital. We lost one-twenty-fifth of ours in |)rivate practice; 
a result verj^ nearly as goml as Dr. Bennett's, though ours were all in chil- 
dren under 15 years of age, and of 37, whose ages were recorded, 19 were 
under 5 years (2 in the first year, 3 in the second, 5 in the third, 4 in the 
tourth, 5 in the fifth ». Dr. Bennett condemns bleeding almost wholly ; we 
tfx>k blood in 16 of 39 primary, and in 2 of 7 complicated ca.'^es, and did 
not deplete at all in the 2 fatal ca«es. M. Barthez report* 212 ca,«ert, 
treated by the expectant nietho^l, with only 2 deaths, or le^s than one in 
a hundred ; and these caset*, too, in children between 2 and 15 years of 
age, in hospital practice. These last stati^ties are the most surprising we 
have seen. We have been unable to find the original memoir of M. I'ur- 



182 PNEUMONIA. 

thez, but have seeu the report made to the Academy of Medicine, by M. 
Blache {Bulletin de VAcad. Imp. de Medecine, t. xxx, p. 21), on the me- 
moir, in which it is stated that " the author has taken care to eliminate 
the lobular or generalized pneumonias, the pseudo-lobar pneumonias, 
broncho-pneumonias, and catarrhal pneumonias ; he has also thrown 
aside the lobar congestions which occur in the course of low fevers, and 
the secondary lobar hepatizations ; that is to say, those which occur in 
the course of any well-determined disease, and particularly tuberculosis." 
We cannot help thinking that the elimination of so many forms of pneu- 
monia, must be a chief reason for the very great success of the plan of 
treatment used. 

This much, however, has been plainly established by the observations 
and experience of late years, that the old plan of bleeding, as a rule of 
absolute practice, merely because of the existence of pneumonia, and es- 
pecially the Sangrado system of bleeding, coup sur coup, was a gross 
mistake, and one which did great harm. But we do not think it has been 
proved that the restorative or expectant system, to the exclusion of blood- 
letting under any circumstances, is always and inevitably the right one. 
We have been led to think that bloodletting was not the only cause of the 
heavy mortality under the old systems of treatment, but that the use of 
such agents as antimony, ipecacuanha, and perhaps calomel, in large and 
frequently administered, and long-continued doses (and particularly the 
antimony) by their action upon the stomach, in destroying all power to 
take and digest food, and by the general prostration which their action 
(especially antimony) upon the nervous system occasioned, were answer- 
able for a large share of the fatal results of those days. We doubt, in 
fact, whether depletion, used in anything like moderation, is not safer for 
the patient than the continued use, for two or three days, of nauseants and 
depressants, more particularly of antimony. But of the action of anti- 
mony upon children, we shall speak more at length hereafter. 

Our own opinion,, after the enlarged experience of later years, is, that 
depletion should not be used save in exceptional cases. When the pneu- 
monia is pursuing a regular and safe course, it is best to trust to the sim- 
ple means to be spoken of hereafter — to follow a mild expectant method. 
Where the physician doubts as to its propriety, and especially when he is 
young and inexperienced, it is safest to abstain from it entirely, or to em- 
ploy it only in a very moderate degree. But there is a certain class of 
cases, in which we believe that local depletion, by cups and leeches, is not 
only allowable but most useful. When the subject is vigorous and strong, 
with a fine sanguification ; when the temperature is very high ; the pulse 
strong and full ; the muscular force good, and the side-pain and cough 
very severe, we think that the local abstraction of from two to four ounces 
of blood, at the age of three or four years, has great power to relieve all 
these symptoms. Again, when the dyspnoea is very great ; when the heart 
pulsates with great force, whilst the pulse is small and feeble, showing that 
the right heart is overloaded, and the arteries comparatively empty, in con- 
sequence of obstruction to the passage of blood through the lungs ; and 
when the child is tolerably vigorous, and not reduced by previous illness, 



TREATMENT — ANTIMONY. 183 

a moderate venesection is often of more use, and of more efficacy in pal- 
liating these conditions, than any treatment we know of. The quantity to 
be taken should seldom be over four ounces, at the ages of from three 
years and upwards. We venture upon these statement,^ the more boldly 
when we tind such men as Chambers and Niemeyer, and even Bennett, 
giving the same advice. Dr. Bennett (loc. cif.) lays down amongst his 
axioms the following: ** Small bloodlettings, of from six to eiglit ounces, 
may be used in extreme cases, more especially in double pneumonia and 
broncho-pneumonia, as a palliative to relieve tension of the bloodvessels 
and congestion of the right heart and lungs." 'Siemeyer (Te.vt- Book of 
Pract. Med., Amer. ed., vol. i, p. 184) says, pithily: "Highly as I prize 
venesection, however, in certain emergencies which may arise in the dis- 
ease, I had rather that any one, dear to me, and sick of pneumonia, were 
in the hands of a homoeopath, than in the hands of a physician who thinks 
that he carries the issue of the malady upon the point of his lancet." He 
recommends venesection in three conditions: 1. When the pneumonia lias 
attacked a vigorous and hitherto healthy subject, is of recent occurrence, 
the temperature being higher than 105^ F., and the frequence of the pulse 
rating at more than 120 beats a minute. "Here danger threatens from 
the violence of the fever, and free venesection will reduce the temperature, 
and lessen the frequence of the pulse. In those who are already debilitated 
and ansemic, bleeding increases the danger of exhaustion. Should the fever 
be moderate, bloodletting is not indicated, even in healthy and vigorous 
individuals." 2. " When collateral a?dema, in the portions of the lung 
unaftlcted by pneumonia, is causing danger to life, the pressure of the 
blood is reduced by bleeding, and by prevention of further transudation 
of serum into the vesicles, insufficience of the lung, and carbonic acid poi- 
soning are averted. Whenever the great frequence of respiration, in the 
commencement of pneumonia, cannot be traced to fever, pain, and to the 
extent of the pneumonic process alone, as soon as a serous, foamy expectora- 
tion appears, together uith a respiration of forty or fifty breaths a minute, 
and when the rattle in the chest does not cease for awhile after the patient 
has coughed, we ought at once to practice a copious venesection, in order 
to reduce the mass of blood, and to moderate the collateral pressure. The 
third indication for bleeding arises upon the appearance of symptoms of 
pre.-sure uprjn the brain, not headache and delirium, but a state of stupor 
or transient paralysis." We have made this long quotation because the 
authority is so high, and because we have nowhere found such clear and 
conci.se statements upon this most important point of practice. 

Antimony. — In a former edition of this work it wa.s stated that tartar 
emetic, in the dose recommended by some of tlie highest authorities of the 
day, had been found by us a very dangerous drug. Time has but confirmed 
this opinion. At that time we were in the habit of administering it in doses 
of a forty-fifth or sixtieth of a grain every hour or two hours. This waa 
at a time when Rilliet and Barthez used it in doses of from two to four 
grains, dissolved in four ounces of water, in twenty-four hours, for very 
young children, and for those who were older six gniins in the ^ame space 
of time. They continued it for two, three, or four days, and advised its 



184 PNEUMONIA. 

suspension should it give rise to excessive vomiting or severe diarrhoea. 
Dr. West at that time gave it in doses of one-eighth of a grain, at the age 
of two years, every ten minutes, until vomiting was produced ; to be con- 
tinued every hour or two afterwards for a period of twenty-four or thirty- 
six hours. Dr. West had reduced the doses, and the time of continuing it, 
one-half, between the time referred to and the date of his essay on pneu- 
monia, published in 1843. 

The doses used by us, as mentioned above, may seem to some who have 
not employed them ludicrously small, but we soon found that even they 
were quite frequently, in certain constitutions, more than could be given 
■with safety. Antimony, even in those small quantities, sometimes caused 
a very peculiar general prostration. Perhaps without any vomiting what- 
ever, or with only a rare effort at that act, the patient would refuse all 
nourishment, become very pale and weak, grow limp and motionless, take 
on a haggard and pinched expression of face, pass into a state in which it 
would pay no attention to what was going on around, be very peevish and 
irritable when disturbed, get a very frequent and feeble pulse, and look to 
an experienced eye as though a very little deeper degree of such prostra- 
tion might end fatally. After seeing this condition a few times, and find- 
ing that the withdrawal of the drug and the use of small doses of brandy 
(ten to twenty drops in water or milk) every hour or two hours, was fol- 
lowed by rapid improvement, we learned the greatest caution in the use of 
the remedy. Of late years we never use tartar emetic at all, but give, not 
unfrequently, in strong and vigorous children, with high febrile heat and 
rapid circulation, small doses of the precipitated sulphuret of antimony, 
always watching its effects carefully, and withdrawing it at once should 
the above symptoms make their appearance. The formula found most 
useful and safest is the following : 

B;- — Antimon. Sulphurat., .... gr. j. 
Pulv. Doveri, . . . . . gr iij. 

Sacch. Alb , . . . . . . gr. xij. 

M. et div. in chart, no. xii. One to be given every two, three, or four hours. 

To infants under two years of age it is best to give no antimony at all. 

Mercury. — In former years, in obedience to the prevailing rules of the 
day, we gave calomel in very moderate quantities in some cases of pneu- 
monia. We never felt sure that it was of any special service, and of latter 
years do not give it except under some very clear indication. When, how- 
ever, especially in the early stage, there are signs of gastro-hepatic con- 
gestion, such as a flabby tongue with whitish fur, fulness of the hypochon- 
driac regions, anorexia and perhaps nausea, a few small doses of calomel, 
or of blue mass followed by a mild saline laxative will be followed by 
relief. 

Salines. — Citrate of potash, either in the form of the neutral mixture or 
dissolved simply in water with a little sugar, is one of the best febrifuges 
that can be used. In doses of two and a half grains to children over three 
or four years old, and half a grain to a grain for younger children and 



TREATMENT — IPECACUANHA — MURIATE OF AMMONIA. 185 

infants, every two hours, it is an excellent remedy. It may bo given alone, 
or combined witli small doses of syrup of ipecacuanha and opium. Spirit 
of nitrous ether may be added when the urine is scanty, or when the ipe- 
cacuanha cannot be borne. 

The solution of acetate of ammonia, either alone or combined with the 
spirit of nitrous ether, is useful when the child is feeble, and when the 
stomach or bowels are irritable, in which case the citrate of potash some- 
times otiends the stomach and acts upon the bowels. The dose of this 
remedy may be from twenty or thirty drops to half a drachm or a drachm, 
accordintr to the age, in sweetened water, or some aromatic water, every 
two hours. 

Quinia is unquestionably a remedy of great value in both forms of the 
pneumonia of children. When given in full doses, it diminishes the intense 
febrile heat and the great rapidity of pulse ; and, at the same time, is be- 
lieved by many observers to possess a tendency to check the extension of 
the exudation process. It is usually perfectly well accepted by the stomach, 
and does not interfere with the power of taking food ; while, on the other 
hand, by its tonic influence it must be of service in sustaining the system 
until the necessary stages of this exhausting disease have been passed. 

Ipecacuanha is preferable to antimony in all conditions except those 
referred to above. In infants under two years of age, in children of highly 
nervous temperament, or of feeble and delicate constitutions, in most cases 
of the secondary form, and in all mild cases, it is much safer than the other 
drug. The most convenient preparation is the syrup, of which ten drops 
may be given every two hours at four yeai*s of age, five drops between one 
and three years, and from one to three drops to infants of two or three 
months. It is often useful to combine the spirit of nitrous ether with it, 
and, when the stomach is irritable, or the patient very restless and irritable, 
to add small doses of opium. When the patient is much oppressed by the 
presence of secretions in the bronchia, and not too much prostrated, an 
emetic is oft^n very useful. Ipecacuanha is the most suitable remedy for 
this purpose, a? it produces less exhaustion and depression than any other, 
except, perhaps, alum. 

Muriate of Ammonia has of late years been very largely employed in 
the acute pulmonary affections both of adults and children. It has seemed 
to us to possess the power of hastening the softening and resolution of the 
exudation, and when there is expectoration, of rendering it less viscous 
and freer. The best period for administering it is in the lobar form after 
the hepatization is clearly established and the attack has rear-hed it,s full 
development ; or, in the catarrhal form, after the acute symptoms have 
somewhat subsided. It may then be given, associated with the febrifuge 
employed, or else dissolved in a little syrup of Tolu or syrup of wild cherry 
bark and water. The proper dose is one grain for children under 2 years 
of age, and 2 to 3 for those between 2 and o years, given every <», o, or 4 
hours, according to it« effect and the wav in which it is toUraf'-d by the 
Stomach. 

If the resolution of the exudation do^- not progress rapidly, and c-jk'- 



186 PNEUMONIA. 

cially if symptoms of exhaustion make their appearance, the carbonate of 
ammonia may be substituted in about the same doses, for the muriate. 

Purgatives. — A ptirgative dose, with or without a previous small dose of 
a mercurial, is useful at the beginning of the attack, when the child is 
constipated, and when the abdomen is tumid and hard. A teaspoouful of 
castor oil, or two teaspoonfuls of simple syrup of rhubarb, will answer 
every purpose. After this period cathartics need be used only so as to keep 
the bowels moderately soluble. If they are moved spontaneously every 
two or three days, there is no occasion to give purgative doses. If they 
do not move, a simple enema, or the doses mentioned, will be sufficient. 
Violent or frequently repeated doses of purgatives are injurious, by ex- 
hausting the patient through the disturbance of the stomach which they 
occasion, or by setting up diarrhoea. 

External Applications. — MM. Rilliet and Barthez. were of opinion that 
neither blisters. Burgundy pitch, nor tartar-emetic plasters, exerted the 
least influence upon any one of the symptoms of pneumonia, but that, on 
the contrary, they increased the fever. Dr. West gave up the use of blis- 
ters entirely, in consequence of the irritation and fever they occasioned, 
and because of the disposition to sloughing which he observed to follow 
their use amongst the poor. At one time we thought we had observed 
great benefit from the use of a blister when other means had failed to pro- 
duce some moderation of the symptoms after four or five days. If they 
are used at all, it ought to be with great care, especially in very young or 
feeble children, whose nutrition is depraved. In children of less than two 
or three years old, a blister should never remain on the skin longer than 
two hours. As a general rule, the mother should be told positively to re- 
move it at the end of one hour and a half, even though the surface be still 
unchanged. A warm bread-and-milk poultice is then to be used as a 
dressing, and this rarely fails to cause vesication in a few hours. Employed 
in this way, we have had but once the misfortune to see a blistered surface 
slough, and this occurred in a child whose skin had been very much irri- 
tated by frictions with amber oil and ammonia. 

Since the spring of 1845, however, when we were led to make frequent 
use of mustard poultices and foot-baths in the treatment of the bronchitis 
and pneumonia of measles, we have rarely employed blisters, but have 
preferred the employment several times a day of the remedies just indi- 
cated. Two parts of Indian meal and one of mustard, for young children, 
and for those who are older equal parts of each, are to be mixed with warm 
water, and spread thickly like a poultice on a piece of flannel or rag five 
or six inches square. This is to be covered with fine muslin, linen, or gauze, 
and applied first over the back and then the front of the thorax. It may 
remain from fifteen to forty minutes, or until the child cries or complains, 
or until the skin is reddened. The mustard foot-baths may be employed 
at the same time with the poultices. These applications are useful when- 
ever the oppression is very great, and, when resorted to in the evening, 
they often allay irritability, and dispose the child to sleep. The number 
of applications to be made in a day must depend on the urgency of the 



II 
•I 



TREATMENT — TONICS AND STIMULANTS. 187 

symptoms. We have employed them from ouce a day to every two or 
three hours. 

The use of hot linseed-meal poultices, so highly recommended by Dr. 
Chambers, of London, we have found apparently of much service. The 
poultices should be spread quite thick on a cloth or flannel as broad as 
the circumference of the thorax, and deep enough to cover the whole 
chest, from the collar bones to the hypochondria. The size of the poul- 
tice will be determined by the amount of lung-tissue, though we usually 
have them spread large enough to cover the whole affected side, even if 
but a portion of the lung be involved. They should be changed several 
times during the day, and care should be taken that a fresh hot poultice 
is ready for application before the one in place has been removed. In 
order to keep them in place, it is often necessary to have a tape stitched 
on in front, and a tape behind, which can be tied over the shoulder in the 
manner of a shoulder-strap. 

Tonics and silmiiltuiUs are to be resorted to in cases which manifest un- 
doubted signs of debility. When, therefore, the attack- occurs in a feeble 
child ; in secondary cases ; when the inflammation remains unresolved 
after the use of other remedies, and when extensive bronchial respiration 
persists, though the fever has moderated; or when, in any case, during 
the acute stage, the child falls into a typhoid state, as shown by pallor of 
the surface, frequent, uneven pulse, dry tongue, prostration of muscular 
power, and either incessant jactitation or the listless quiet of exhaustion ; 
attention must be paid to the state of the constitution even more than to 
the local disease. The vital forces must be sustained and strengthened in 
order to give time and power to carry on the operations necessary for the 
removal of the local obstruction. To effect this purpose, we must depend 
upon the use of food, alcoholic stimuli, and certain toni{^-J. The food most 
suitable for such a condition is milk, animal broths, soft-boiled eggs, and 
perhaps small quantities of raw or slightly cooked meats. The be^t stim- 
ulants are brandy, given either in the milk or in water, as the child will 
bfe-t take it, and wine and water, or wine-whey. The amount of brandy 
given may be stated as 3,4, or 5 teaspoonfuls in the course of 24 hours at 
4 years of age. The best ionie to give in conjunction with the alcoholic 
stimulus is, as has already been stated, quinia, which should be adminis- 
tered in the quantity of from gr. iv to gr. \"j in 24 hours, given in divided 
doees. When the exhaustion is marked, especially when associated with 
great embarrassment of respiration and copious viscid secretion from the 
brrinchial tubes, we should recommend the use of the muriate or carbonate 
of ammonia, either of which may be given in mucilage, in doses of gr. ij 
to iij every 3 or 4 hours, at 4 or o years of age. 

Opium is constantly of great service in the treatment of pneumonia. 
It should always be used when the patient .suffers much, either from the 
side-pain or from cough, whether this be hara**sing and exhausting from 
its mere frecjuency and persistence, or from its effect in developing the 
stitch ; when there is painful jactitation, an unusual degree of distrcMs and 
malaise, or marked tendency to morbid vigilance. When the fever is very 
high, the pulse vibrating, the nerves on a rack, opium is of the greatest 



188 * PNEUMONIA. 

advantage. The mere comfort it gives is a good warrant for its use, but 
it has long seemed to us to aid in shortening the duration and lessening 
the severity of the constitutional disturbance. 

The choice of the preparation, and the doses and times of administra- 
tion, must vary in different cases. When used early in the case, to act 
upon the circulation and allay general irritability, it is best to give it with 
the febrifuge every two or three hours. When used to control cough, it 
can be added to the sulphurated antimony in the form of Dover's powder, 
as already suggested, or to the syrup of ipecacuanha and spirit of nitrous 
ether, in a liquid form ; or when the cough is particularly troublesome at 
night, as often happens, it can be given with more advantage in a single 
dose, or two doses in the evening. The preparations we have found most 
useful are, laudanum, especially the tr. opii deodorata, paregoric, solution 
of morphia, or Dover's powder. Under six months of age, half a drop 
of laudanum, from five to ten drops of paregoric, or two or three drops of 
the solution of morphia, may be given, and repeated twice or three times 
in the twenty-four hours, according to the effects. From the age of six 
months to the end of the second year, these doses may be doubled. In 
the third and fourth years, two drops of laudanum, ten to twenty of pare- 
goric, five to ten of solution of morphia, may be used several times a day. 
Where the remedy is given every two or three hours, we have found one 
drop of laudanum quite enough at the ages last mentioned. When the 
dose is given only at night, from three to five drops of laudanum, ten to 
fifteen of solution of morphia, and thirty to fifty of paregoric are suffi- 
cient as a general rule. After the age of four and five years, the doses 
must be increased in proportion to the age. In very young children, the 
doses given at first should always be watched with a good deal of care, 
and never carried to such a quantity, or continued long enough, to in- 
duce constant and heavy drowsiness or stupor. In some instances of very 
nervous and hypersesthetic children, in whom there is determined, by the 
violence of the reaction, a degree of irritability of the nervous centres 
tending to the tetanic state, the doses must be much larger than those 
mentioned ; but here the physician should see the patient himself at least 
twice, and sometimes three times in the day, to watch and regulate by 
the dose the exact action of the drug. We have occasionally seen the 
cough most harassing and exhausting in its effect, occurring almost with 
every breath, and lasting for twelve and twenty-four hours. Under such 
circumstances, a mixture like the following has proved most beneficial in 
our hands : 



1 



R.— Tr. Opii Deodorat., gtt. xxxij. 

Vin. Antimon., . 
Ext. Valerian, Fl., 
Syrup, Simp., 
Aquae, . 
Dose, a teaspoonful every hou 



gtt. xxxij. 

f^iss. — M. 
or two hours, at the age of four years and up- 



wards, until the cough is controlled. 

Paregoric, in the proportion of two drachms to half an ounce, in place 
of the laudanum, sometimes proves more soothing and comforting. 



GENERAL MANAGEMENT. 189 

General Management. — Since the reign of restorative nuMliciue has 
set in, the jj^eueral mauairement of the patient has reeeivod a di'iiree of at- 
tention which it had never attracted before. Under the expectant plan it 
constitutes, indeed, the chief portion of the treatment. The most impor- 
tant point;? to be attended to under this head are tlie diet, drinks, eK)thing, 
air, and state of repose. 

The patient ought not to be allowed to go entirely without food even in 
the early days of the disease, neither should there be any ettort made to 
stuff the child with large quantities of nourishment. The appetite is 
nearly always in great measure abolished, at first, and food is unwillingly 
taken except in very small quantities. A nursing child must not be al- 
lowed to nurse as heartily as usual. If it attempts to do so, it is probably 
from thirst and not from hunger. Water, therefore, should be offered to 
it from time to time, and the breast be allowed only every three or four 
hours for short periods. Weaned children should have only milk, always 
reduced by the addition of half or a third water, and pure water ought 
to be given frequently. The thii-^t in this disease is intense, and the phy- 
sician should himself see that the patient has water freely. We have seen 
the most violent and obstinate screaming, and painful restlessness, quieted 
at once by a copious draught of cold water. In children over two and 
three years of age, milk and water is still the best food ; but when this 
is refused, thin chicken or beef tea may be given in doses of a wineglass- 
ful or a gill every four hours. After three or four days have passed by, 
the administration of food is a very important part of the treatment. 
The child should now be induced, by persuasion and even gentle force, to 
take a little food at least three or four times in the twenty-four hours. As 
the severity of the symptoms subsides, the food ought to be increased in 
quantity. 

The clothing ought to be such as to keep the body comfortably warm. 
In winter, which is the season when the disease almost always occurs, thin 
and .soft flannels ought to be worn, and, when the child is very restless, 
either in the bed or on the lap, a sack made high in the neck, with the 
sleeves to the wrists, buttoning in front, and consisting of a soft and pli- 
able woollen stuff, ought to be put over the bed-dress. 

The room ought to be, if possible, a large one with a high ceiling, well 
ventilated, warmed by an open fire, and kept at a temperature of 65^ to 
68^. If the child is very young and delicate, a temperature of 70° is not 
too high, if only the ventilation be good. 

The bed or crib is the proper place for a child with ])n<Mitii()iiia. The 
lap of the mother or nurse is a poor substitute for an even, elastic, and 
steady mattress. We have long endeavored to keep our little patimts in 
bed. A very young infant must, of course, often be taken up to be nursed, 
soothed, or cleansed, but, as soon as possible, it ought to be replaced, in 
the crib. Children a year or two old can generally, with g(K»d manage- 
ment, be kept the greater part of the time in bed. Those of three and 
four years old and upwards ought always to be confined to the bed. A 
little firmness on the part of the mother will almost always accomplish 
this end, and it is a highly important one, and well worth ev^n a quarrel 



190 BRONCHITIS. 

at the beginniDg of the sickness. We have seen a child three years old 
kept by a weak and overtender mother and grandmother nursed on the 
lap for three weeks, until they were exhausted and demoralized, and the 
child had oedematous feet from their dependent position during so long a 
time. 

Kepose and quiet of mind and body, as complete as can be attained, 
are things of great value, and to secure them a good bed and a cheerful 
and resolute manner on the part of the nurse are as important for the child 
as for the adult. It is only in bed, too, that an even temperature and an 
avoidance of draught can be fully secured. A direction given by some of 
the French writers, and by Dr. Gerhard, is not to allow very young chil- 
dren to lie for too long a time in one position in bed, or in the nurse's 
arms, as it is apt to produce a stasis of blood in the dependent portions of 
the lungs, and thus to maintain or increase the disease. Dr. West recom- 
mends, whenever the inflammation has reached an advanced stage, or in- 
volved a considerable extent of the lungs, that the patient be moved with 
great care and gentleness, lest, as he has often seen occur, convulsions be 
produced. 



ARTICLE III. 



BRONCHITIS. 



Definition ; Synonyms ; Frequency ; Forms. — The term bronchitis 
is now universally employed to express inflammation of the mucous mem- 
brane of the bronchia ; frequently it is called catarrh, and catarrhal fever. 

It has been stated, under the head of Pneumonia, that many of the cases 
known amongst us by the popular term catarrh fever, are in fact, cases 
of pneumonia. We shall on account of this misapplication of names en- 
deavor to draw the distinction between bronchitis and pneumonia with 
great care. 

Since bronchitis and pneumonia have been more carefully distinguished 
in the mortality returns of this city, bronchitis is found to be the cause of 
a much smaller proportion of deaths than would have formerly appeared. 

Thus, during the seven years ending with 1869, the total mortality from 
all causes (excluding still-born children) was, at all ages, 105,785 ; under 
fifteen years of age, 50,151 ; and under five years, 43,322. The mortality 
from bronchitis during this period was, at all ages, 969, or less than 1 per 
cent, of the entire mortality ; under fifteen years, 509, or 1.01 per cent, of 
the mortality under that age ; and under five years, 495, or 1.14 per cent, 
of the mortality under that age. 

It is, however, one of the most frequent of the diseases of childhood, es- 
pecially during the winter and early spring months. It is said to be more 
common as a secondary than as an idiopathic disease. Of 115 cases ob- 
served by MM. Rilliet and Barthez, only 21 were idiopathic. Of 128 



CAUSES. 191 

cases, however, that we have recorded, 76 were primary, and the remain- 
ing 47 secondary. The diseases during the course of which it is most apt 
to occur, are pertussis and measles. 

We shall describe three forms of the disease: 1, acute bronchi fitt of mod- 
erate severity ; 2, capi/lary bronchitis, or acute sufiocative catarrh ; 3, suba- 
cute or chronic bronchitis. 

Causes. — Amongst the predisposinrj causes of the disease, a(j/e is one of 
the most important. MM. Rilliet and Barthez suppose it to be much more 
common in children over, than in those under five years of age. Of one 
hundrt^d and fifteen cases observed by them, thirty-seven occurred between 
the ages of one and five years, and seventy-eight between six and fifteen 
years of age. It is scarcely fair, however, to compare a period of nine 
years with one of only four, as is done in the above statements. Of one 
hundred and twenty cases that we have seen in private practice, in which 
the age was noted, fifty-four occurred between birth and two years of age; 
thirty-nine between two and four years ; twelve between four and six ; six 
between six and ten; and three between ten and fifteen. Of eighty-one 
cases under four years of age, of which we have kept an accurate record, 
eleven occurred in the first half of the first year of life, twenty in the second 
half, making thirty-one for the first year; twenty-one occurred in the second 
year of life, nineteen in the third, and ten only in the fourth, showing that 
the liability is greatest in the first year of life, and particularly in the last 
half of that year, that it continues very strong in the second and third 
years, being nearly equal in each of these, and that it then suddenly di- 
minishes. It would seem also that the simple acute, and the acute suffo- 
cative forms are most common under six years of age, while the secondary 
cases occur more frequently after that age. 

As to the influence of sex on the liability to the disease, it would appear 
from our experience to be rather more common in girls than boys, since of 
DJnety-nine cases in which this point was noted, fifty-four occurred in girls 
and forty-five in boys. The fact of its being more fretpiently a secondary 
than a primary affection has already been noticed, though this has not been 
true of our experience. The diseases in which the largest number of cases 
occur are measles, pertussis, and typhoid fever. The secondary cases are 
most common, of course, during the prevalence of the disease whose prog- 
ress they complicate, whilst the {primary cases are most common in the 
cold months of the year, and especially in the autumn and spring. The 
reader is referred to the table in the article on pneumonia for a full exhi- 
bition of the effects of season and temperature upon the frequency of this 
disease. Bronchitis is sf>metime> epidemic amongst children as it is amongst 
adulte. It is important also to be aware that there is a strong tendency to 
attacks of bronchitis in rickety children. 

The only exciting causes whose effect* in the production of the disease 
seem clearly proved are sudden transitions from a warm into a cold at- 
mosphere, and sometimes the contrary change ; prolonged exposure to cold, 
particularly when combined with moi.sture; and the inspiration of irritat- 
ing gases. We believe ourselves, from what we have seen in this city 
during the last thirty years, that the most fruitful caiwe of bronchitis, and 



192 BRONCHITIS. 

also of pneumonia, croup and angina in early life, is the style of dress 
almost universally used for young children. The dress is entirely insuffi- 
cient. It consists usually of a small flannel shirt, cut very low in the neck, 
scarcely covering the shoulders, and without sleeves ; of a flannel petti- 
coat, a muslin petticoat, and an outer dress made in nearly every case of 
cotton. The dress, like the flannel shirt, is cut low in the neck, is without 
sleeves, and fits very loosely about the chest, so that not only are the whole 
neck, the shoulders, and the arms exposed to the air, but in consequence 
of the looseness of the dress about the neck, it is fair to say that the upper 
half of the thorax is also without covering. In the infant, from birth to 
the age of six or eight months, the dress is made long, a wise provision so 
far as it goes, but from the time the skirts are shortened, up to the age of 
four or five years in boys, when happily the time for boys' clothes arrives, 
and throughout childhood in girls, the trunk of the body and the arms are 
dressed, or rather left undressed, as above described. But, not only are 
the neck, breast, and arms left bare, but in many children the greater part 
of the legs also is kept uncovered, or at least, short stockings, scarcely ris- 
ing above the ankles, and muslin or sometimes Canton flannel drawers, not 
reaching, or scarcely reaching to the knees, leave exposed to the air a 
large proportion of the cutaneous surface of the lower extremities. Now, 
in this dress, the child passes the day in a house, the sitting-rooms of which 
are heated usually to 68° or 70°, but in which the entries, and sometimes 
the parlors, are frequently at a temperature of 60°, 50°, or even lower, as 
we ourselves have tested with the thermometer. And not only are the 
entries and parlors, and indeed all the rooms, saving the one or two in 
constant use, frequently at the temperature just mentioned, but the air of 
the nursery itself is often allowed, through the negligence of the servants, 
and especially early in the morning, to fall to 60° or 58°, or possibly lower 
still. 

That the style of clothing is not correct, is proved by the simple facts 
that children who are dressed nearly the same in summer as in winter, 
suffer scarcely at all from colds in the summer season, when the thermom- 
eter seldom ranges below 76°, and is usually above that point ; and also 
by the fact that adults have been driven by long and almost forgotten 
experience, to wear clothing twice or three times as warm as that which 
they put upon their children. How constantly do we see the strong and 
fully-developed man comfortably enveloped in a warm, long-sleeved flannel 
shirt, woollen or thick cotton drawers, and cloth pantaloons, vest, and 
coat, in the same room and in the same temperature with the little — often 
puny, pale, and half-naked — child. But it is almost impossible to make 
people understand that children need as much clothing as themselves. 
They always insist upon it that, as the child passes the greater part of the 
day in the house, it cannot require as much clothing as the adult who is 
obliged to go out and face the weather ; forgetting, or refusing to see, that 
the former wears less than half, or probably not more than a fourth, as 
much covering as the latter, and that the adult, when in the house, and in 
the same rooms as the child, finds his one-half or three-fourths warmer 
clothing not at all superabundant or oppressive. 



1 



ANATOMICAL LESIONS. 193 

We have repeatedly had patients to get well of chronic catarrhal and 
laryngeal coughs, and to cease to have, as before, frequent recurrences of 
these disorders, under the simple treatment of a long-sleeved and high- 
necked merino or Haunel shirt; long woollen stockings, and stout Canton 
flannel drawers coming down below the knees; and that, too, after the most 
patient and assiduous, and sometimes over assiduous trials of drugr, diet, and 
confinement to the house, had entirely failed of any permanent good efiects. 
The fact is, that though there are some few children who can bear the 
dress above-described without injury, there are a great many more who, 
while they wear it, either suffer all winter long from frequently repeated 
attacks of cold, in the shape of croup, chronic laryngeal irritation with 
cough, chronic pharyngitis, bronchitis, acute or chronic, or more rarely 
pneumonia ; or, if they escape these direct effects, resulting from the con- 
stant and rapid waste of their caloric, they are rendered more pale, thin, 
and delicate-looking than they would be v.ere their vital forces husbanded 
by warm clothing, instead of being wasted in the constant-struggle to keep 
up the Beat of the uncovered body at the natural point. 

AxATOMiCAL Lesions. — We shall describe, first, the lesions met with 
in cases in which the disease is confined to the larger bronchia, the in- 
flammation not extending into the capillary tubes ; and next, those ob- 
served in cases in which the disease has attacked the capillary bronchia. 
The former are those which constitute the form designated under the title 
of acute ordinary bronchitis of moderate severity, while the latter are 
those to which the term capillary has been applied. Patients seldom die 
of the first-named variety of the disease alone; but as it often occurs as an 
accidental complication, or a more or less essential part of difl^erent severe 
and frequently fatal diseases, the morbid alterations which characterize it 
have been very thoroughly studied and ascertained. 

The morbid alterations of acute ordinary bronchitis always exist in both 
lungs, and are confined to the larger bronchia, ceasing on a line with the 
-mailer tubes and the capillary divisions. The most constant alteration 
is redness of the bronchial mucous membrane, caused by injection of the 
Tiiinute vessels of that and the subjacent tissues, and varying in shade 
from a rosy to a bright-red or brownish tint. The mucous membrane is 
sometimes softened, a change which can be ascertained only in the largest 
tubes, and it sometimes presents a thickened, unequal, and rough a{)i)('ar- 
ance. Ulcerations are very rare. The inflamed bronchia contain a more 
or less abundant viscid, transparent, or opaque yellowish mucus. 

In cipiUnry bronchitiji the alterations of the mucous membrane of the 
capillary tui>es do not always reveal the existence of the disease. That 
membrane is sometimes pale in the minute ramifications, and exhibitn 
morbid changes only in tbo.se of medium size. The alterations of the 
membrane consist ib redness, which is made up either of a number of fine 
points, .seated in the membrane itself, or of arborizations seate<l both in 
the membrane and the cellular tissue beneath ; it sometimes presents a 
granulated appearance, and it may he raore or less thickened, and its con- 
sistence diminished. The bronchia arc usually filled and almost obliter- 
ated from the secoudar}' divisions to the final ramifications, by a substance 

13 



194 BRONCHITIS. 

of a yellowish-white or yellow color, non-aerated, and composed of a thick 
muco-pus. Portions of false membrane are sometimes, not as a rule, but 
exceptionally, found mixed with the secretions just described, while in 
other instances false membranes alone are present in certain tubes. The 
false membrane may exist in the form of patches, or it may constitute a 
lining to the whole extent of the bronchial ramifications. It is usually 
soft and but slightly adherent, and the mucous membrane beneath is either 
very pale, and of its usual consistence, or red, softened, and rough. The 
different kinds of secretion are commonly most abundant in the bronchia 
of the inferior lobes. 

In a good many of the cases another lesion, dilatation of the bronchia, 
is also found upon examination. This alteration evidently occurs under 
the influence of the inflammation ; it may aftect either the length of the 
air-tubes, or only their extremities. In the former condition the tube 
continues of the same size, or becomes gradually larger from one of its 
early subdivisions, until it reaches the surface of the lung. In the latter 
condition a section of the lung presents an areolar appearance, from the 
presence of a multitude of little rounded cavities, communicating with 
each other and with the bronchia, of which they seem to be a continua- 
tion. These cavities are generally central, though they are sometimes 
found upon the surface of the lung, in which case they are formed of the 
pleura, lined by the thinned membranes of the dilated bronchus. 

The fact of these cavities being true dilatations of the bronchia, has 
been called in question by Dr. Gairdner {loe. cit., p. 76), who believes, on 
the contrary, " that almost all the so-called bronchial dilatations, and all 
of those presenting the abrupt, sacculated character here alluded to, are in 
fact the result of ulcerative excavations of the lung communicating with the 
bronchia." He supposes them to be the result of the expansion of certain 
small cavities, frequently met with in the bronchitis of children, and to 
be described directly under the title of vacuoles or bronchial abscesses, 
either by ulceration or by the act of inspiration. 

In addition to the lesions already described as existing in bronchitis, 
there is another one, not unfrequently met with, to which we shall call 
attention, that to which the French writers apply the term vacuoles, and 
which Dr. Gairdner designates as bronchial abscess. The latter author 
states that in the centre of the collapsed lobules of a lung affected with 
acute bronchitis, there are found, not unfrequently, small collections of 
pus, varying in size from that of a hemp-seed to double or treble that 
volume. "These small abscesses present, on section, an appearance so 
much like that of softening tubercles, as to be very readily mistaken by 
many persons for these bodies ; and the resemblance is all the greater on 
account of the peculiar limited form of the condensation by which they 
are generally surrounded, which, when felt by the touch from the exterior 
of the lung, is exceedingly deceptive. In their interior, however, these 
little abscesses contain, in the recent state, a very fluid pus ; moreover, 
they are often met with as acute lesions produced by a few days of illness, 
and without a trace of tubercle in any other organ." When the pus is 
scraped or pressed out of these abscesses, in their recent form, they are 



ANATOMICAL LESIONS. 195 

fouud to be lined with a fine villous membrane, while in other instances 
they are not abruptly limited, but the pus appears to lie in contact with 
the surniunding pulmonary tissue. The bronchia leading to the part of 
the lung thus aflected, are found, when incised, to be much inflamed, their 
mucous membrane being vascular, thickened, and covered with pus; and 
some of them can be observed to communicate with the purulent collec- 
tions, the mucous membrane having been, at the point of communication, 
destroyed by ulceration, and either stopping short abruptly, or becoming 
gradually incorporated with the false membrane lining the abscess. Some- 
times these abscesses or vacuoles communicate not only with the bronchia, 
but also with each other, without difliculty ; sometimes, according to Dr. 
Gairdner, they break into one another and form more considerable excava- 
tions, but, more commonly, they remain of limited size, preserving per- 
fectly the direction and relations of the bronchial tubes. They occur both 
in the diflused and lobular form of condensation from collapse of the lung, 
and both forms may sometimes be seen in the same lung. 

The alteration just now described has excited a good deal of discussion 
amongst medical writers, and has been very differently accounted for. 
^IM. Killiet and Barthez regard it as a simple terminal dilatation of the 
bronchia, while MM. Barrier, and Legendre and Bailly, consider it to de- 
pend on a purulent breaking down of the vesicles of one or more lobules. 
MM. Hardy and Behier look upon it as a lesion of a complex nature, par- 
taking both of dilatation of the bronchia and of pulmonary emphysema. 
Dr. Gairdner, as already mentioned, describes them as abscesses, and 
-rates that they ** unquestionably arise from the accumulation of pus pri- 
marily in the extreme bronchial tubes of the collapsed lobules." This 
view, which is closely similar to that of MM, Barrier, and Legendre and 
Bailly, is, it appears to us, much the most reasonable that has been 
adduced. 

MM. Rilliet and Barthez, in their second edition, as has already been 
-rated, in the article on post-natal collapse, describe at great length a state 
jf congei'tion of the lung-tissue, as a most important element in the ana- 
tomical alterations of the bronchitic diseases. This congestion usually 
assumes one of two forms : it may be distinctly lobular, consisting then of 
•iisseminated patches, or, as more generally happens, large numbers of con- 
tiguous lobules are affected, when it takes the form of generalized lobular 
'^ongestion. These congested portions of the lung are almost always 
attended with more or less well-marked collapse of the vesicles, so that 
there is associate<l together the conditions of congestion and collapse. It 
is this combination of bronchitis, with congestion and collapse, which was 
formerly described by them, under the titles of lobular and generalized 
lobular pneumonia. The alteration to which the term carnification has 
been applie<l, and which not unfrcHjuently coexist* with bronchitis, they 
regard as different from the above, and as consisting in a simple collapse 
of the lung-tissue, without the active or passive congestion which exists in 
he first form. The principal causes of this condition are, according to 
hem, debility and catarrh. The signs of catarrhal inflammation are, they 
-tate, never scarcely absent. In only four out of thirty -one cases did they 



196 BRONCHITIS. 

fail to discover them. We have dwelt, in our article on pneumonia, on 
the lesions of catarrhal pneumonia, or lobular pneumonia as it is now gen- 
erally recognized ; and it is probable that at least in some of the cases 
described as above by Rilliet and Barthez the condition has really been of 
that form of inflammation of the pulmonary tissue. 

The parenchyma of the lung presents, in bronchitis, different appear- 
ances in different cases. It is supple, crepitant, and of a rose-gray color, 
but does not collapse, especially the anterior portions, when the thorax is 
opened, as does healthy lung. This imperfect collapse depends either on 
the fact that the thick mucus and muco-pus which fill and obstruct the 
bronchia, prevent the contained air from being expelled by the natural 
elasticity of the lung, or,, when no secretions exist to produce this effect, 
on the loss of the natural elasticity of the organ. Another cause is the 
existence of vesicular emphysema, a lesion observed to a greater or less 
extent in nearly all the cases, and affecting usually the summit of the 
lung, its anterior edge, and also its posterior or lateral edge. In a large 
number of cases, and particularly in those occurring in young children 
and in weakly and debilitated subjects of all ages, the tissue surrounding 
the diseased bronchia exhibits the condition which has already been fully 
described in the article on atelectasis, under the title of collapse of the 
lung. The extent and mode of distribution of this lesion, its peculiar and 
distinguishing characters, its causes and mode of production, and the 
method of treating it, have been carefully discussed in the article just 
referred to, and we shall make no further allusion to it, in this place, ex- 
cept to beg the reader, who is not already fully acquainted with it in all 
its bearings, not to suppose himself master of the subject of bronchitis 
until he has also fully studied that of collapse, as the two go together so 
constantly, and the latter is practically so important, especially in children, 
as to make it essential for him to understand both. 

The lesions just described as characteristic of acute bronchitis, are also 
met with in the chronic form of the disease. The dilatation of the air^ 
tubes, however, presents different features. The calibre of the enlarged 
tube is often much greater, its walls are whitish and uneven, and cry under 
the scalpel, and beneath the mucous lining may be seen hypertrophied 
transverse fibres. The mucous membrane itself remains smooth and pol- 
ished, while the tissues beneath are thickened and hypertrophied. 

Symptoms ; Course. of the Disease ; Duration. — Acute simple bron- 
chitis exhibits very different degrees of severity in different cases, being in 
some extremely mild and benign, and in others so much more severe, as to 
border closely on the capillary form of the disease. In its mildest form, 
it occasions merely slight cough and stuffing, a little mucous rale over the 
larger bronchia, with a total absence of dyspnoea, or of decided fever. In 
cases rather more severe than this, it begins with a moderately frequent 
cough, which, dry at first, soon becomes loose, and is neither paroxysmal 
nor painful. The expression of the face remains natural, with the excep- 
tion of an appearance of slight languor. The pulse and respiration are 
but slightly accelerated ; the external phenomena of the latter, an impor- 
tant means of diagnosis in infants, remain natural;, it occurs without jerk- 



SYMPTOMS. 197 

ing, the rhythm continues even and regular, and there is no violent action 
of the ala? nasi. The j^ercussion is not modified. Auscultation reveals in 
very young children a mixture of mucous and sibilant rales on both side^, 
which come and go, and are of short duration ; in older children, the moist 
rales predominate, and commonly last several days. These ^^ounds are 
seated in the larger bronchia. The temper of the child is not much changed ; 
the appetite is not entirely lost ; there is neither vomiting nor diarrha^a ; 
and the fever is usually slight. The disease remains nearly stationary, or 
increases for a variable length of time, after which the cough becomes 
looser, and in children over five years of age, is sometimes attended with 
expectoration of frothy or yellowish mucous sputa, whilst under that age 
there is no expectoration. The fever and other symptoms, with the excep- 
tion of the cough, now subside; the cough remains some days longer. 

In attacks still more severe than this, the symptoms resemble very much 
iiose just now described, but they are all more intense. The cough is 
tighter, more frequent, harassing, and especially it is more painful, as shown 
by the fact that the child cries and complains, and that a marked expres- 
sion of pain passes over the face at the instant of coughing. There is more 
fever, the skin being hot and dry, and the pulse more frequent, rising often 
to 130 or 140, and in one case to 156. The respiration is hurried, and 
though not attended with the same labor and anxiety as in the capillary 
variety, it is evidently oppressed ; it counted in three cases, 60, 60, and 62. 
The temperature is considerably elevated, but not so much so as in pneu- 
monia, rarely rising above 102^ or 102.5°. There is more restlessness, 
fretfulne?is, and general distress; the appetite is greatly diminished or lost, 
and infants nurse with less avidity than usual, or refuse to nurse at all for 
several hours together. In case^ of this kind, the physical signs are more 
iecided than in those of milder degree, there being a greater abundance of 
mucous and dry rales, and generally some subcrepitant rule, and they are 
heard over a larger extent of surface, usually over the lower half, two-thirds, 
r even the whole dorsum of the chest The symptoms are almost always 
lost marked and severe in the after-part of the day and night. Very 
Tten the patient will be comparatively easy and comfortable in the moru- 
la, but as the day goes on, he becomes more feverish, restless, and fretful ; 
:he cough grows more troublesome, more frequent, and tighter ; the breath- 
ing is quicker and more oppressed ; the face is more flushed ; the sleep ia 
■Token and disturbed, and the child may appear through the night quite 
1 ; and yet a-s morning approaches, the symptoms moderate, the skin often 
-oftens and becomes moist, and the whole aspect of the case shows a great 
nmelioration in the manifestations of the <lisea.se, 

Acconling to Handfield Jones, this almost invariable tendency to aggra- 
vation of catarrhal disorden? during the night is due to a lowering of the 
nerve-power, the vaso-raotor nerves partaking of the general debility, and 
thus allowing dilatation of the arteries, and causing increased bypeneraia 
f the affected parts with more abundant exudation. 

The duration of this form of bronchitis is very uncertain ; the idiopathic 
ases last usually from four to seven or eight days, though they may last 



198 CAPILLARY BRONCHITIS. 

from sixteen to twenty-five ; the duration of the secondary cases depends, 
in great measure, on the nature of the diseases during which they occur. 

In any of these different degrees of acute simple bronchitis, the patient 
is liable, especially if it be a weak and debilitated child, or a young infant, 
to sudden and alarming aggravations of the symptoms. The breathing 
becomes suddenly either greatly increased in frequency, or excessively 
labored and oppressed, the surface becomes pale, the expression dull and 
languid, or distressed, the child is drowsy and inattentive, or uneasy and 
restless, the hands and feet are coolish, the act of sucking is performed 
with difficulty, or the child refuses the breast entirely, and it is evident 
that, from some sudden change in the condition of the lungs, the act of 
respiration and the aeration of the blood are very seriously interfered with. 
If this sudden aggravation of the symptoms be unattended with a corre- 
sponding increase of the febrile phenomena, as marked by greater heat of 
skin and augmented action of the circulation, it is altogether probable that 
it depends on a collapse of larger or smaller portions of the pulmonary 
texture, and if, on examination, we discover dulness on percussion, distant 
bronchial respiration, and cessation or greatly diminished abundance of 
the bronchitic rales, over parts of the chest where a few hours or a day 
before there had existed all the physical signs of bronchitis, there can be 
no longer any doubt as to the cause of the suddenly increased severity of 
the symptoms — it must be owing to collapse. 

It must however be carefully borne in mind that it is in the course of 
bronchitis that catarrhal pneumonia is most apt to occur. The symptoms 
which indicate this accident have been detailed in the article on pneumonia 
(page 168) : the most prominent being the rapid increase in dyspnoea, the 
sudden and marked elevation of temperature, the change in the character of 
cough, the evidences of pain in the chest, and the absence, in most instances, 
of any positive physical signs of consolidation of lung-tissue. If these symp- 
toms be contrasted with those above stated as indicating the occurrence of 
collapse of the lung, it will be seen that with care any error in diagnosis 
may be avoided. 

Capillary bronchitis, or acute suffocative catarrh, may succeed to the form 
just described, or appear as an idiopathic affection. Under either condi- 
tion the general symptoms are more threatening than in the preceding 
form, and the disease soon assumes all the appearances of great severity. 
The child is very uneasy and restless, constantly changing its position, 
moving about in the crib or bed, or insisting upon being changed from the 
bed to the lap, or from the lap to the bed. In one case that came under 
our charge the oppression was very great, and the only position in which 
the child was at all satisfied was resting on the mother's arms, with the 
front of its chest applied against her breast, and the head hanging over 
her shoulder. The expression of the face is anxious and disturbed, and its 
color usually pale or slightly bluish. The temper is irritable or subdued ; 
the child hates to be disturbed, and generally chooses its own position. 
The respiration is very much accelerated, running up in a very short time 
to 60, 70, or 80, and is usually more or less irregular, and evidently 
laborious and difficult. The cough is very frequent, troublesome, and 



SYMPTOMS OF CAPILLARY BRONCHITIS. 199 

evidently paiuful ; it occurs iu short paroxysms usually, with or without 
stridulous sound, is at first dry, and after a few days is accompanied, in 
older children, by whitish or yellowish expectoration. In some instances, 
the sputa consist of mucus tinged with blood, or of pure blood even, and 
still more mrely of mucus mingled with small shreds of false niemhrane. 
The appetite is entirely lost ; the tongue is usually moist and furred white ; 
there is acute thirst, and yet, in severe cases, though the presence of acute 
thirst is evident from the manner of the child, only very small quantities 
of water are taken, from the impossibility of suspending the respiration 
long enough to allow of more being swallowed ; the drink is gulped rapidly, 
suddenly, and with great difiiculty, and after a time is refused almost en- 
tirely from this cause. In children old enough to talk, the speech is short 
and abrupt ; the patient dislikes to speak, from the fact that the effort 
obliges him to suspend momentarily the act of breathing. Fever sets in 
from an early period ; the skin is hot and dry, and the face is flushed at 
first, though it soon becomes pale in most cases, from the approach of an 
asphyctic state. The pulse becomes frequent, rising soon after the onset to 
130, 140, 1.50, or higher; it is full and hard early in the attack. The res- 
onance on j)ercussion is not modified. Auscultation reveals at first sibilant 
rale mixed with some mucous rales ; but soon a fine subcrepitant rale is heard 
over all the lower parts of both lungs behind, and approaching sometimes, 
os'er the bases of the lungs, the character of crepitus. After a time the 
subcrepitant rale is heard over the whole, or nearly the whole dorsum of 
the chest, and to a greater or less extent, though not so well marked as 
behind, over the anterior regions of the thorax. This rale is audible at 
first both in inspiration and expiration, and is very distinct, but at a later 
period, it is heard only in the inspiration, or there is substituted for it a 
mucous rale, while the subcrepitant rale is now heard only in the forced 
inspirations during coughing or crying. These nlles are fugitive and 
irregular, disappearing or changing from one to the other after fits of 
coughing. 

Should the case not take a favorable turn, which change would be indi- 
cated by a moderation in the symptoms just detailed, and especially by 
easier and fuller respiration, with diminution of the amount of the sub- 
crepitant rule, and return of the natural respiratory murmur over some 
parts of the chest, the syraptoraa look still more alarming. The oppression 
becomes excessive ; fits of dyspnoea occur, in which the child is extremely 
restles.«J and distressed, tossing itself about on the bed ; the respiration runs 
up to 80, 90, or more, in the minute, and is attended with violent action 
of the alie nasi ; the pulse grows more and more frequent, rising to 150 
or 180, and it loses force and volume; and the face assumes a whitish or 
slightly bluish tint, looks puflTed, and is sometimes covered with iKTs|)ira- 
tion. As the fatal termination approache^s more nearly, the pulse becomes 
small, thready, and irregular; the respiration is uneven, irregular, ster- 
torous, and often slower than before ; the cough is smothered and less fre- 
quent; the restlessness generally diminisiies, and the child sinks into quiet, 
and often becomes comatose : the paroxysms of euffocation are less fre- 



200 CHRONIC BRONCHITIS. 

quently renewed, and less violent, and death occurs in a state of quiet in- 
sensibility, or is preceded by partial or general convulsive movements. 

The duration of this form may be stated to be, on the average, between 
five and eight days. It may, however, end fatally in a much shorter time. 
In an example that we saw, in a child four months and a half old, death 
occurred in twenty-six hours from the onset. Dr. Eberle states that it 
seldom lasts longer than two or three days, and that in very young infants 
death sometimes occurs on the first day. M. Bouchut gives as the duration 
in children at the breast, from two days to a week. Dr. West mentions a 
case that proved fatal in less than forty-eight hours. In the favorable 
cases that we have seen the duration was seven, eight, and ten days. 

Subacute and chronic bronchitis generally follows one of the acute forms 
of the disease. The character and severity of the symptoms vary very 
much in diff"erent cases. We have known some children to present for 
several months together, in the winter season, slight bronchitic symptoms, 
consisting in wheezing and somewhat accelerated breathing, cough, more 
or less frequent ; occasional feverishness, especially at night ; some diminu- 
tion of appetite and loss of flesh ; and sibilant and sonorous with mucous 
rales, heard here and there, but still without severe symptoms during the 
greater part of the time. Children laboring under this kind of bronchitic 
irritation are liable to, and generally have, from time to time, more or less 
sharp attacks of acute bronchitis, in which they present the usual symptoms 
of that form of the disease. These attacks are very apt to occur coincidently 
with changes in the weather, and in some patients the liability to them is 
so great, from the excessive susceptibility of the system to the weather, 
that no care will prevent them. In some instances, w^e are very sure that 
an aggravation of the symptoms of the chronic form constantly occurs 
whenever the child is about cutting additional teeth, whilst in the intervals 
between the appearance of the successive teeth, the child remains compara- 
tively well. We believe that the cause of the aggravation, at the moment 
of cutting the teeth, is to be looked for, not only in the act of dentition it- 
self, but in the circumstance that the liability to cold is greatly increased 
at that particular moment, probably because the forces of the system are 
so weakened by the effort of the dentition as to lessen the power of resist- 
ance against the disturbing influence of a changing, and particularly of a 
falling temperature. 

Cases of the mild kind of chronic bronchitis that we have just been de- 
scribing, usually get well under proper medical, and especially under proper 
hygienic means, after several weeks or two or three months ; while in other 
instances the disorder continues, in spite of every precaution, throughout 
the winter and spring, and only ceases as the warm summer months arrive. 
We have known the same disposition to show itself again in the following 
winter. In other instances again, the frequent attacks of severe bronchi- 
tis, together with the effect of a constant slight bronchitic inflammation, 
ends in the production of an emphysematous state of parts of the lung, 
and the child exhibits more or less marked asthmatic symptoms, which 
show themselves whenever a slight increase of the bronchitis occurs, and 
whenever the digestive system is deranged by imprudence in diet or other 



SYMPTOMS. 201 

causes. It is particularly iu such eases as these that the bronchial affectiou 
is apt to be associated with rickets, and we should, therefore, always care- 
fully search for the evidences of this latter disease. 

In other examples of chronic bronchitis the symptoms are much more 
severe. Thes;e cases almost always follow an acute attack of the disease. 
The frequency of the respiration and the attacks of dyspna\i persist; the 
cough is loose and paroxysmal, and the pulse frequent and small ; evening 
exacerbations of fever take phice, and the tace and sometimes tlie rest of 
the surface are often covered with perspiration. Auscultation reveals tubal 
blowing, with mucous or loud sonorous rales, which seem to indicate the 
presence of dilatation of the bronchia. Emaciation makes rapid i)rogress, 
the face is pale and blanched, the eyes sunken, the nostrils are covered with 
mucous or bloody crusts, and the lips ulcerated. Strength diminishes pro- 
gressively ; the appetite is lost, and the thirst acute; colliquative diarrhica 
appears; and after twenty, forty, or more days, the child perishes in the 
last stage of mai^asmus. This form of bronchitis often simulates phthisis 
very closely, and may last for a long time, even several years. It rarely 
occurs under the age of five years. The expectoration consists of purulent 
or pseudo-membranous secretions in variable quantity. 

Particular Symptoms — Physical Signs. — The dry rales are amongst 
the most fre(|ueut physical signs in bronchitis. They may be sibilant or 
sonorous; they seldom exist alone, but are accompanied with mucous rales, 
and dimini>h as the latter become more abundant. As the dry rales cease 
to be heard, they are replaced by mucous or subcrepitant rales, or by feeble- 
ness of the respiratory murmur. The sibilant nlle is often heard over the 
whole thorax, though it may be confined to the posterior portions. It is 
not restricted to cases of inflammation of the larger bronchia only, but is 
alsfj present in capillary bronchitis. 

Moi^t Rides. — Mucous and subcrepitant rales do not exist in all cases 
without exception, as they may be absent in such as are very mild. They 
may generally be heard over both sides behind, more rarely over the whole 
of the chest, and almost always both in inspiration and expiration. They 
are generally persistent, but are sometimes suspended for a moment and 
replared by sibilant rale or feeble respiratory sound. 

Ft»ble rejtpiratory murmur is sometimes observed. It is not permanent, 
occurs during the interruptions of the subcrepitant or sonorous rale, and 
does not occupy the whole extent of the thorax, but is limited ; it is inter- 
mittent, and is not accompanied by diminished resonance. 

When dilatation of the bronchia exist,s to a considerable extent it gives 
rise to bronchial or even cavernous re?*piration, and to bronchial resonance 
of the voice, cr)*, and cough. The bronchial respiration differs from that 
of pneumonia by iU tone, and by it* intermitting character. The percus- 
sion is generally sonorous. 

It ha.-* already been stated in the account of the symptoms that it hap- 
pens not infrequently in severe bronchitis, and also in mild bronchitis 
occurring in debilitated children, that the respiratory sound suddenly be- 
comes feeble, or even entirely 8upprei*sed, over parts of the lung, while in 
other instances a distant and im|)erfectly marked bronchial rcrjiiration 



202 CHRONIC BRONCHITIS. 

takes the place of the natural vesicular murmur. These changes are 
heard either over small disseminated points of the lung, or over large sur- 
faces ; they are associated with more or less evident dulness on percussion, 
and what particularly characterizes them, they are very fugitive, being 
present at one examination, and absent perhaps at the next. The appear- 
ance of these changes in the phenomena afforded by auscultation depends 
on the occurrence of diffused or lobular collapse of the tissue of the lungs. 

The physical signs above described are not invariably present in bron- 
chitis. Cases do occur, though they are very rare, in which auscultation 
fails to reveal the characteristic signs of the disease. 

Rational Symptoms. — The rational symptoms are of the utmost im- 
portance in informing us of the degree of severity of the attack. 

Cough generally exists from the beginning, being in mild cases more or 
less frequent, and either dry or loose, while in severe cases it is frequent 
or very frequent, at first dry and then moist, and very rarely hoarse. In 
acute capillary bronchitis, the cough has a peculiar character. From 
the first day it occurs in short paroxysms, lasting from a quarter to half 
a minute. The paroxysms vary greatly in violence, occur at irregular in- 
tervals, and generally continue without interruption to the fatal termina- 
tion, though they are sometimes replaced by simple loose cough a few 
days before that event. The cough is rarely painful, so long as the in- 
flammation remains simple. Expectoration is never present in very young 
children. When it occurs in those over five years of age, it consists, in 
the mild form, of a sero-mucous or of a frothy and yellowish mucous 
liquid. In general bronchitis it is sero-mucous at first, becoming after a 
few days yellowish and more or less viscous ; it is sometimes nummular 
and sometimes amorphous. 

In the capillary form, as already mentioned, the sputa consist of mucus 
tinged with blood, or of pure blood even, and in some rare cases there are 
mixed with the mucus, shreds of false membrane, which may present the 
form of casts of the minute ramifications of the bronchial tubes. 

The respiration varies in its characters according to the extent and vio- 
lence of the disease. In mild cases, it is not much increased in frequency, 
being generally between 28 and 40 in the minute. In more violent cases, 
and particularly when the disease implicates the smaller bronchia, it be- 
comes very frequent. The acceleration is slight in the beginning, but 
increases regularly as the case progresses ; thus it may be 30 at first, and 
rise afterwards to 50, 60, 80, and even 90. When not very much quick- 
ened, it remains even and regular ; when more so, it becomes somewhat 
laborious, and the movements of the chest are full and ample ; in severe 
cases, attended with much dyspnoea, it is often irregular, or assumes the 
characters to which M. Bouchut has applied the term expiratory, that is, 
the order of the movements is inverted, each respiration beginning with 
the expiration, leaving a pause between the inspiration and expiration, in- 
stead of between the expiration and inspiration. In chronic bronchitis 
with copious purulent or pseudo-membranous expectoration, the dyspnoea 
is generally habitual. 

Fever. — The fever is slight in mild cases, the pulse rising very little 



DIAGNOSIS. 203 

above its Datural standard. The heat is not great, and the febrile move- 
ment usually subsides before the termination of the disease. In the sinive 
or capillary form, on the contrary, the pulse is always frequent, and con- 
tinues to increase in rapidity as the disease advances. It varies between 
104, 120, 160. and in very violent cases, rises as high as 200. Early in 
the attack, it is vibrating, rather full and regular, whilst in fatal cases, it 
always becomes small, irregular, trembling, and unequal. The skin is 
generally hot in proportion to the activity of the pulse, except towards the 
termination, when the extremities often become cool. The temperature 
does not rise so rapidly nor reach so high a point as in pneumonia. Thus 
Roger gives as the highest temperature observed by himself in bronchitis 
102.2°; while the average in his cases of the acute febrile form was 100.9°. 
The skin is almost always dry. In very young children it is often pale and 
cold, and covered with perspiration from the beginning. 

The expression of the face is unchanged in mild cases, but when the dis- 
ease is violent and extensive, becomes deeply altered after a few days. The 
eyes are then surrounded by bluish rings, and the expression is uneasy, 
anxious, and sometimes, but less frequently, exhibits an appearance of pro- 
found exhaustion. The anxiety of the countenance increases with the op- 
pression ; the alae nasi are dilated, the nostrils dry or incrusted, and the 
lips and face, which are extremely pale or momentarily congested, assume 
a purple tint, particularly after the paroxysms of cough. 

The deciibitis is indifferent at first, but as the disease progresses, the child 
lies with its thorax more or less elevated, or is restless and constantly chang- 
ing its position. 

In dangerous cases there is great distress and restlessness after the first 
few days, or even from the beginning. In some instances the irritability 
and peevishness are excessive and uncontrollable, while in others there is 
heaviness and somnolence, especially towards the termination of fatal cases. 
Some of the disorders of the nervous system just mentioned are present in 
all the grave cases. 

Digestive Orgam. — There is moderate thirst and incomplete anorexia 
when the disease is mild, but, when severe, the thirst is generally acute, 
and the appetite entirely lost. The state of the bowels varies. The tongue 
and abdomen present no special characters in idiopathic cases. 

Urine. — The great majority of recorded obser\'ations of the condition 
of this excretion in bronchitis, relate to the disease as occurring in the 
adult. The followinir summary is taken from Parkes : the condition of 
the urine in bronchitis varies greatly with the grade of the disea.«se ; in 
the grave forms, it resembles that of pneumonia, the urea being increased, 
and the chloride of sodium at times entirely absent. The urine has also 
been quite frequently found to be temporarily albuminous in such cases. 

DiA<^;Nf»sis. — The mild form of bronchitis, in whioh the inflammation 
is confined to the larger bronchia, is not likely to be mi.stakcn for any- 
thing but the early stage of hooping-cough. The diagnosis can be made 
only by attention to the different characters of the cough, which i;* more 
spasmodic and paroxysmal io pertussis, by the absence of fever in that 



204 BRONCHITIS. 

disease, and by the development of the peculiar symptoms of each, as the 
case progresses. 

The diagnosis between bronchitis and pneumonia is seldom difficult, ex- 
cept when the latter is grafted upon the former, or in cases of partial pneu- 
monia, attended with bronchitis. In well-marked cases of the two diseases, 
there can be no difficulty. The restriction of the physical signs to one side 
alone of the chest in pneumonia, the peculiar crepitus of that disease, or 
when this is not heard, the fineness of the subcrepitant rale, limitedto the 
upper or lower regions of one lung, the bronchial respiration and bron- 
chophony, the dulness on percussion over the seat of disease, the greater 
sharpness and severity and the different location of the pain, the more 
acute character of the febrile reaction, as marked by the pulse, skin, and 
thirst, the more abrupt and higher elevation of temperature, and the 
kind of expectoration, when there is any, will always enable us to dis- 
tinguish the two with almost absolute certainty. In cases, however, in 
which the two are combined, the diagnosis is not so easy, but even here 
the presence of dulness on percussion, and of crepitant or fine subcrepi- 
tant rale, or, when these are absent, of pure metallic bronchial respiration 
with bronchophony, over limited portions of the lung, will generally ren- 
der the matter clear. 

The sudden supervention of dulness on percussion over large portions of 
one of the lobes of a lung, or over disseminated patches, with feeble or 
absent respiratory sound, or with muffled and distant bronchial respiration, 
generally indicates the occurrence of collapse in the part of the lung over 
■which these signs exist ; and when these symptoms show themselves without 
any increase in the severity of the febrile reaction, but rather with a diminu- 
tion, there is every reason to suppose that they depend, not upon inflam- 
matory condensation of the parenchyma of the lung, but upon simple col- 
lapse, from the presence of obstructive secretions in the bronchia. 

Dr. Gairdner {loc. cit., p. 6) has called attention to a difference in the 
character of the dyspnoea in the two diseases, which is, we think, of con- 
siderable importance, and which we have often remarked ourselves. In 
bronchitis, of any considerable severity, the respiration is always evidently 
labored ; it is performed only with the aid of all the accessory muscles of 
respiration, and in really severe cases it is extremely laborious, the inspira- 
tion being long-drawn, exhausting, and inadequate. The dyspnoea of pure 
pneumonia is, on the other hand, quite different. It is merely an " accelera- 
tion of the respiration, without any of the heaving or straining inspiration 
observed in bronchitis, or in cases where the two diseases are combined." 
Dr. Gairdner states that he has repeatedly seen patients affected with a 
great extent of pneumonia of both lungs, in whom the extreme lividity and 
rapid respiration, numbering fifty or sixty in the minute, showed infallibly 
the amount to which the function of the lung was interfered with, who, 
nevertheless, lay quietly in bed, breathing without any of the violent effort, 
or disposition to assume the erect posture, so constantly accompanying the 
more dangerous forms of bronchitis. In children these differences are even 
more marked than in adults. 

Chronic bronchitis may be mistaken for tuberculosis of the lungs or of 



PROGNOSIS — TREATMENT. 205 

the bronchial glands. The distinction can be made only by careful study 
of the history of the case, and of the phenomena afforded by auscultation 
and percussion, which are detailed in our article on tuberculosis. 

It is also important that we should not overlook the evidences of rachitis, 
which, as before stated, very often exist in children who are predisposed to 
attacks of bronchitis. 

Prognosis. — Bronchitis is rarely a fatal disease, so long as it remains 
contined to the larger bronchia, constituting the acute simple form, of 
moderate severity. Capillary bronchitis is, on the contrary, a very 
dangerous affection at all times and at all ages. Even ordinary, simple 
bronchitis, however, may prove fatal in young infants, and in debilitated 
children of all ages, from the supervention of collapse of portions of the 
pulmonary tissue ; and it is necessary, therefore, that the prognosis given 
should always be guarded, when the disease occurs under either of these 
two conditions. The prognosis differs also in the primary and secondary 
forms of the disease, since, as might be expected, the danger is much 
greater in the latter than in the former variety. 

We have met with a large number of cases of bronchitis, out of which 
we have kept more or less copious notes of 123. Of these, 108 were mild, 
and 15 capillary. Of the 108 mild cases, 6d were primary, all of which 
recovered ; and 43 secondary, of which 2 died. Of the 15 capillary cases, 
11 were primary, of which one died, and four secondary, of which 2 died. 
Of the whole number, 123 in all, 5 proved fatal. The danger from the 
disease depends very much also upon the hygienic conditions in which the 
patients are placed. In hospitals and amongst the poor it is much more 
dangerous than in private practice amongst the easy classes of society. 
This is shown by the fact that all the cases of the capillary form observed 
by MM. Rilliet and Barthez and Fauvel, in ho^pital practice, proved 
fatal, while of 15 cases seen by ourselves, in private practice, under the 
most favorable hygienic conditions, only 3 died. 

The symptoms indicating great danger are, increase of the dyspna\a; 
extreme anxiety, small and irregular pulse, coolness or coldness of the 
skin with clammy sweats, much jactitation, and delirium, drowsiness, or 
coma. With such symptoms the danger is greater and the fatal termina- 
tion more imminent in proportion as the child is younger, less robust, and 
its constitution exhausted by preceding or coincident disease. 

Tkkatmext. — The acute simple form of bronchitis is frecjuently so mild 
as to need no other treatment than careful attention to the hygienic condi- 
tion of the patient, and the administration of some simple febrifn^'o and 
expectorant. The child ought to be confined to one room, in a mild and 
uniform temperature, and should be kept quiet until the develo|)ment of 
the symptoms shows what is to be the type of the attack. The degree of 
repose of the body necessary will depend on the presence or ab?iencc of 
fever. We believe that the practice of keeping the body <juiot in all 
febrile di.^orders, is one of the most impcjrtant therapeutic means we liave. 
It is long since one of us, having seen his father insist upon putting 
children to bed for a feverish cold, began to follow the same practice. 



206 BRONCHITIS. 

Time and experience have made even more clear to us the wisdom of 
the practice, especially in regard to very young children. 

So soon as the attack of bronchitis becomes severe enough to cause 
fever, whether the fever be continuous or occur only in the afternoon 
and night, the patient ought to be confined to the lap or bed. Suckling 
children, and those under three years of age, must be allowed to lie on the 
lap at times, but even they may be taught, very early, to rest quietly in 
the crib the greater part of the twenty-four hours. Children over three 
years old can almost always be taught to stay in their beds by a little 
management and authority, if only the parent is resolute. If not very 
sick, they should have a large pillow put up against the head of the crib 
or bed, and against this they should be placed in a sitting posture, with 
the bedclothes arranged over the lap ; and, in cool or cold weather, with a 
light flannel sack over the night-dress. Here they ought to be kept all 
day, allowed to change their position as they wish, and they should be 
kept as cheerful and happy as possible with toys, books, pictures, readings, 
tale-telling, or what not. Under such circumstances, a new and interesting 
toy will often do more good by far than any drug in the materia medica. 
We have often been surprised, and delighted, too, to find a bronchitis 
which had been hanging over a young child for several days or a week, 
getting gradually worse, day by day, under the trotting-about system, be- 
gin to mend from the day the child was put to bed, and disappear in two 
or three days, and that, too, without any change in the other remedies. 

The clothing ought to be warm, and yet not suflficient to produce free 
pei-spiration, as this, by sudden exposure and evaporation, often induces 
chilliness. The diet must be simple, and may consist of any of the milk 
preparations, with or without bread, or bread and butter. Light soups in 
the middle of the day, or roast potatoes or apples, with bread, may gener- 
ally be allowed. 

As for medicines, in this mild form they are of comparatively little con- 
sequence, if the above measures be carried out. In the after part of the 
day, when fever sets in, we may prescribe a febrifuge of citrate of potash, 
such as the following, for children of two to four years old : 



R.— Potass. Citrat., 


. . . zl 


Syriip. Ipecac, 


. f^j vel ^ij. 


Tr. Opii Camph., . 


. f5J vel 3ij. 


Syrup. Simp., 


. . . f^ss. 


Aquae, .... 


. adf^iij.-M. 



A teaspoonful every two or three hours. 

This should be given until the child sleeps, and occasionally in the 
night if there be cough and restlessness. At six months of age, the fol- 
lowing may be used in the same manner : 

R. — Syrup. Ipecac, 

Tr. Opii Camph., aa . . . . fjss. 

Spts. ^Ether. Nitros., vel 

Liq. Ammon. Acetat., .... fjij. 

Syrup. Simp., fgv. 

Aquae, fjij.— M. 

Give a teaspoonful every two hours. 



TREATMENT. 207 

If the fever is very slight, and the cough only moderately severe, it is 
often well to use no drug through the ihiy, but to give in the evening, two 
hours before bedtime, and again at bedtime, some simple expectorant and 
anodyne. Thus at two or three months of age, three to five drops of syrup 
of ipecacuanha with five of paregoric, or half a drop to a drop of laudanum ; 
at one or two years, ten drops of the syrup with ten to twenty of paregoric, 
or two of laudanum ; at five to ten years, ten to twenty drops of the syrup, 
with twenty to thirty of paregoric or five of laudanum. Tlie laudanum is 
often better than paregoric, as it produces a more decided and lasiting im- 
pression on the nervous system, and appears to extend its useful control 
over the symptoms further into the foHowing day. 

In this very mild form there is no necessity for giving active purgatives. 
If the bowels are moved once in the day, or once in two days, it is best not 
to interfere with them. If, however, the patient be constipated, a little 
simple syrup of rhubarb, a teaspoonful of castor oil, or an enema, will be 
quite sufficient. A warm foot-bath, in the evening, containing salt, or, 
better, mustard, will often assist in moderating the cough and promoting 
quiet sleep. 

When, in this acute form, the symptoms assume greater severity, when 
signs of reaction are prominent, the dyspnoea considerable, and the cough 
frequent and harassing, it was formerly quite the custom to employ deple- 
tion. In a former edition of this work, it was stated that the abstraction 
of a few ounces of blood by leeching or cupping, was allowable under 
these circumstances, but that a large majority of such cases would do i>er- 
fectly well without bloodletting of any kind. We now believe that such 
practice is unnecessary in any of this class of cases. Attention to hygienic 
meas^ures is, however, even more important than in the milder cases. Con- 
finement to the bed ought to be a positive rule in such cases. If the bowels 
are not freely moved, a dose of castor oil, rhubarb, or magnesia should be 
given, and the patient then put upon the use of one of the febrifuge mix- 
tures recommended above. When the fever is very high, and the j)atient 
over a year old, antimonial wine may be substituted, with advantage, for 
the syrup of ipecacuanha. 

If, as the case progresses, the bronchial secretions become very abundant 
and the dyspnoea severe, the proper remedy is an emetic. This may be 
ipecacuanha, either in powder or syrup, or a teaspoonful of powdered 
alum, to be repeated if necessary, in ten or fifteen minutes. The latter 
substance is, as we have stated under the head of croup, a very certain, 
efficient, and safe emetic. 

Great benefit may be obtained in all forms of bronchitis, from the more 
or less frequent application of mustard poultices to the front or back of the 
thorax, and from mustard foot-baths. 

The mercurial preparations, so much recommended by many of the 
English and by some of our own writers, are, in our opinion, very seldom, 
if ever, necessary in this, or indeed, in any of the forms of bronchitis in 
children. It may be known that the occurrence of gastric du«turbanc© 
with coated tongue, anorexia, and a torpid state of the bowels, may, in some 



208 BRONCHITIS. 

cases, call for the administration of a single dose of blue mass followed by 
a mild saline laxative. 

MM. Rilliet and Barthez recommend, when the cough and sibilant rale 
persist after the disappearance of the febrile symptoms, the use of small 
doses of the flowers of sulphur. We have ourselves known this remedy to 
prove of service in such cases. About four grains may be given every 
three hours to a child four years old. 

The treatment of the grave acute or capillary form of this disease brings 
up again the question of bloodletting. We, like all the rest of the world, 
have abandoned the practice as a rule, but we think that when, in a case 
of the kind now under consideration, the age being over two years, the 
oppression is very great, the right heart laboring, as shown by a congested 
surface and a throbbing cardiac impulse at the base and left edge of the 
sternum, and the strength not too much reduced, the abstraction of from 
two to four ounces of blood from the interscapular space by cups or leeches, 
would be a useful and legitimate practice. We venture to give this advice 
from our own past experience, and from the views taught quite lately as 
to the effect and value of depletion in relieving the overdistended right 
heart, produced by an obstacle to the pulmonic circulation. 

There is no occasion for repeating here what has been said, under the 
head of pneumonia, in regard to tartar emetic. But if the temperature 
be very high, and the pulse full and strong, we believe that the small doses 
of sulphurated antimony (gr. yL) we then recommended, in combination 
with Dover's powder, every two or three hours, are very useful in moder- 
ating the inflammatory symptoms. Should this be followed by nausea or 
vomiting with exhaustion, they must be suspended at once. The physi- 
cian, and especially the young and inexperienced one, ought to know that 
the susceptibility to the action of all antimonials is singularly different in 
different individuals. We have seen a hearty adult woman thrown into a 
most violent, and for a time alarming choleraic condition, by two doses of 
j^3^th of a grain of tartar emetic each. We saw once a fine hearty boy 
five years of age, vomit violently, grow pale, weak, and faint away, from 
two teaspoonfuls of the mel. scillse compositum, containing in the two doses, 
the fourth of a grain of tartar emetic. And even twelfths of a grain of 
the sulphurated antimony will sometimes cause a degree of nausea and 
prostration in young children which ought not to be kept up, though we 
never saw it occasion such effects as those just mentioned as following the 
use of tartar emetic. When, therefore, the sulphurated antimony acts 
with any undue violence, it ought to be stopped, and we should substitute 
the citrate of potash mixture proposed for the mild form of bronchitis. 

In connection with one of these internal remedies, counter-irritation to 
the surface of the chest will be found of very great service. Indeed, we 
doubt very much whether it is not the most important part of the treat- 
ment. It may be obtained by applications of dry cups to the back of the 
chest, or if this be inconvenient or objected to for any cause, by the use of 
mustard poultices. The poultice ought to be about the size of the hand, 
or one-half larger, and it should be made of one part mustard to two of 
Indian meal or flour. It is to be mixed with warm water, covered with 



I 



TREATMENT. 209 

book muslin or cambric, and applied first to the dorsum of the chest ; after 
having reddened at that point, it should be shifted to the front of the 
ihorax. The time uecessjiry for each contact is usually from ten to fifteen 
or twenty minutes. These applications ought to be renewed once in four 
hours, when the symptoms are only severe, but when these are urgent, 
they should be made every two hours. We are in the habit of depending 
very much, also, on mustard foot-baths. When the oppression is severe, 
and especially when there is any coolness of the extremities, the use of a 
foot-bath simultaneously with the mustard poultice will often assist very 
much in relieving the breathing. 

In very young intants, antimony ought not to be employed, in our opinion, 
and in these, therefore, we need some other remedy. In them ipecacuanha 
is much safer than antimony, and it is quite active enough. The best 
preparation is the syrup, of which from three to five drops may be given 
every two hours to infant? six months old. In older children, also, in 
whom we have been obliged to suspend the antimony, and in those in whom 
its use has been contraindicated by delicacy of constitution or by feeble 
health, the ipecacuanha is preferable. The doses must vary with the age. 
At five years, about ten drops every two hours, in combination with the 
game quantity of spirit of nitrous ether, is a proper dose. When the child 
presents a pale surface and a languid expression, and particularly when 
the skin is very slightly warmer than usual, or coolish, the following pre- 
scription has proved a most useful one in our hands: 

E- — Liq- Ammon. Acetat., f^ss. 

Syrup. Ipecac, ....... f^j. 

Liq. Morph Sulphat., ^tt. xl. 

Syrup. Acacia?, ....... f^j. 

Aquae, f5J^;;.— M. 

Ft. mistura. 

The dose of this is a teaspoonful for a child two years old, to be repeated 
every two hours. Should there be any nausea present, the syrup of ipe- 
cacuanha ought to be reduced to half the quantity; and if there be any 
[drowsiness, the morphia must be left out. 

In very severe cases of the disease, in which the dyspnnea is excessive, the 
ipul.«e rapid and small, the skin cool and pale, the jactitation very great, 
Imnd when there is present extensive mucous and subcrepitant rale, the 
I treatment generally recommended is the frequent employment of emetics, 
I and the French authors usually prefer tartar emetic. For our own part, 
we would not venture to administer, under such circumstances, so power- 
ful a remedy, and especially .so potent a seflative, as antimony, one that we 
liave so often known to cau.«e alarming and dangerous prostration in rhii- 
dren laboring under much slighter disorders than suffocative bronchitis. 
If any emetic be given, it ought to be one of milder action and less |>er- 
turbing influence than tartar emetic, and we should choose, therefore, 
either ipecacuanha or alum. The plan of treatment we prefer, however, 
is to make assiduous u-^e of counter-irritants, and to give internally the 
spirit of Mindererus and a weak decoction of seneka ; or we may combine 

14 



210 BRONCHITIS. 

with the decoction of seneka, in a suitable form, small doses of the muriate 
or carbonate of ammonia. Depletion is, in these cases, entirely contrain- 
dicated ; we may, however, with advantage apply a few small dry cups to 
the dorsum of the chest in the interscapular space, or over the lower lobes 
of the lungs. 

In the bronchitis of children it often becomes proper and necessary to 
make use of stimulants. In the suffocative form, when the symptoms as- 
sume the character described in the last paragraph, small doses of brandy 
or wine-whey may be administered alternately with the spirit of Mindere- 
rus, with great advantage. In milder cases, also, when a sudden increase 
of the dyspnoea occurs, especially in feeble and debilitated subjects, and 
when we may suppose, from the character of the rational and physical signs, 
that collapse of portions of the lung has taken place, it is best to abandon 
for the time all nauseating remedies, and to make use simply of brandy in 
doses of from five to twenty drops every half hour or hour, or of wine-whey 
in dessert or tablespoonful doses, and of counter-irritants, with very light 
fluid nourishment. 

In cases where there is such marked debility, tonics are very useful, and 
good results may be obtained from the administration of quinia, which was 
strongly recommended a few years ago, in the form of capillary bronchitis 
occurring in tropical climates, by Dr. Cameron {London Lancet, November 
9th, 1861). 

In cases of this kind, we have used with great advantage of late years 
small doses of quinia, prepared as follows : 

R. — Quinise Sulphat., gr. vj. 

Acid. Sulph. Dil., gtt. xij. 

Syrup. Simp., f.l^s. 

Aquae, f^ijss. — M. 

Give a teaspoonful every two hours, to children two or three years old. 

In older children the proportion of quinia to the dose ought to be doubled. 
If this should sicken, as it will sometimes do by the disgust its bitterness 
produces, and the consequent resistance to the doses, it is best to lay it aside 
after two or three trials, and to administer the quinia in the form of pow- 
der mixed with a little extract of liquorice and sugar, or to substitute the 
following : 

R.— Elix. Cinchon. Flav., f.^^ij. 

Cura^oa, fjij. 

Acid Sulph. Dil., f^^xij. 

Aquae, f^fij^s. — M. 

Dose, a teaspoonful every two hours. 

Here, as well as in other conditions calling for the use of quinia, but 
where it is difficult to administer it by the mouth, we may give it with 
good effect in the form of suppositories made with cocoa butter, as small 
as possible, and containing one or one and a half grains of quinia each. 

The child ought to be laid on an inclined plane of pillows, and, with 
the exception of turning it gently towards one side or the other, from time 



TREATMENT. 211 

to time, it should be kept perfectly quiet. These directions are particu- 
larly importaut iu very youug children, as it is in them that debility and 
exhaustion of the muscular forces are apt to bring about the state of col- 
lapse just referred to. 

As an example of the kind of case in which stimulants arc useful, and 
to show also the dangerous effects which antimony sometimes produces, we 
will quote the following: A girl between seven and eight years old, was 
attacked while in good health with severe bronchitis. On the second day, 
when we were called, she was very much oppressed, the skin was hot and 
dry, the pulse rapid, and the surfiice pale. We ordered a cupping to the 
amount of four ounces, with some dry cups besides, over the back, and 
two drops of antimonial wine with ten drops of sweet spirit of nitre to be 
given every two hours. On the third day a blister was applied over the 
sternum. On the fourth day we found the child in the afternoon very 
pale, dozing or tossing about on the bed, and sometimes rising up on her 
hands and knees with a bewildered look ; she was inattentive, so that it 
was almost impossible to catch her eye ; the eyes were sunken, and the 
countenance was distressed and anxious; she moaned constantly and 
looked very ill ; the skin was still hot ; there was neither vomiting nor 
purging. The respiration was very much oppressed, and she coughed a 
good deal, though not so much as before. We suspended the antimony 
at once, and gave a teaspoonful of brandy in water, directing it to be re- 
peated in three-quarters of an hour; after the second dose a teaspoonful 
was to be given in a wineglassful of milk and water every two hours 
throughout the night. On the following morning, the child looked better; 
she was less pale, and the eyes were not so excavated. The breathing was 
better. She was still very drowsy, but often waked partially with scream- 
ing and affright, and when awake took very little notice. The milk and 
brandy were continued every two hours. On the afternoon of this day, 
all the unpleasant symptoms had disappeared ; there remained only those 
indicative of a slight bronchitis, and she was soon quite well. Now it 
seems to us exceedingly clear that, had the antimony been continued in 
this case, on account of the hot, dry skin, oppressed breathing, freipient 
cough, and from the absence of vomiting or purging, the child would have 
died. 

The most impf)rtant points in the treatment of rhrom'c cn.^ex, are to insist 
upon a rigorous and persevering regulation of the hygienic conditions of 
the patient, and to make use of tonic, balsamic, and expectorant remedies. 
The child should be carefully and warmly clothed, and, when at home, kept 
in dr\', well-ventilated, and, if possible, airy rooms, at a uniform tempera- 
ture. The living room of such a child ought to be heated in winter by a 
wood-stove, or open wowi-fire, if that is sufficient to keep up a proper tem- 
perature. In our cold winters we have found no plan so good as a well- 
managed wood-stove. Cfjal fires cannot be lowered or extinguished at 
night, as they ought to be, and often keep up. throiiLdi tin- (la\ . to., liij-h a 
temperature. They are unmanageable. 

These, indeed, constitute the truly important part ol th<- trfMiriK-nt, lor 
without them, there is but little chance that drugs of any or of all kinds, 



212 BRONCHITIS. 

diet, or any other measures, will be of any real service. The dress and 
temperature ought to be the first things attended to, and after them, and as 
a secondary matter, certain medical substances will assist in removing the 
disease. The child ought to be taken as often as possible into the air in 
fine weather, and only in fine weather. The diet should be selected with 
a strict view to the improvement of the strength and vigor of the constitu- 
tion ; the food may consist, if the child be of proper age, of light meats, of 
potatoes and rice, as the only vegetables, and unless there is some contra- 
indicating circumstance, of a small quantity of wine with the midday meal. 
The best wine is port, of which one or two tablespoonfuls may be given in 
a considerable quantity of water. 

Tonics must be administered throughout the course of the disease, or 
until the appetite and strength shall have improved to such an extent as 
to make them no longer necessary. The best are quinine, in the dose of a 
grain morning and evening, to be continued for several weeks ; or, when 
the child is thin and anaemic, small doses of arsenic with iron, as recom- 
mended in the article on eczema, and cod-liver oil, in doses of half a tea- 
spoonful to a teaspoonful, three times a day after meals, either pure or in 
some carefully-made emulsion, will often greatly assist in curing these 
chronic forms of catarrh. 

In one case of chronic bronchitis, which came under our care, the 
patient recovered under careful regulation of the hygiene, and the use of 
a decoction of seneka, prepared by boiling a drachm, each, of seneka and 
liquorice-roots, in a pint of water, to half a pint. The decoction was 
strained, and a large teaspoonful given three times a day. The remedy 
was continued during a period of two months ; under its use the child 
grew fat and strong, and recovered entirely from the disease. 

Other remedies, proposed by different authors, are the various resinous 
preparations, the balsams of tolu and copaiba, benzoin, and the sulphur- 
ous mineral waters. In cases of long standing, where mucous rales per- 
sist throughout the lower part of the lungs, showing an abundant morbid 
secretion, tannic acid has been found, by several good authorities, of much 
service. While these means are employed, it is recommended, also, to 
make use of counter-irritants. If any are used, they ought to be such as 
will not produce too much inflammation of the skin ; as, for instance, weak 
Burgundy pitch plasters, daily frictions with hartshorn and sweet oil, a 
simple diachylon plaster, or very mild pustulation with croton oil, or a 
mixture of croton oil and iodine, such as the following : 

R.-Ol. Tiglii, f^j. 

Ether. Sulph., f^j. 

Tr. lodinii, 

Alcoholis, aa f^iij.— M. 

S. Locally. 



EMPHYSEMA. 213 



ARTICLE IV. 



EMPHYSEMA. 



Emphysema of the lungs is of quite frequent occurrence in children. 
It is much more generally met with in an acute form, developed during 
the progress of some pulmonary disease, than in the chronic form which 
it so often assumes in the adult. It is probahle, however, that in many 
cases of asthma in childhood, there is an emphysematous condition of the 
lungs which has been gradually developed at an early period of infancy, 
in consequence of the respiratory embarrassment attending rachitic dis- 
ease of the thorax. There is probably in such children a congenital deli- 
cacy and weakness of the lung-tissue, and subsequently, if the constitution 
is re-established, and the deformity of the thorax removed, as it frequently 
will be, there may be a restoration, to some extent, of the elasticity of the 
pulmonary tissue, with a corresponding decrease in the evidences of emphy- 
sema. It is also highly probable, judging from the frequency with which, 
in fatal cases of acute pulmonary disease in young children, more or less 
marked lesions of emphysema of the lungs are found, that this condition 
is frequently developed to a certain degree in the course of such cases 
which recover, and that subsequently the lung-tissue regains its normal 
state. 

Anatomical Appearances. — The term emphysema of the lungs, is 
usually employed to include two conditions essentially dissimilar, and to 
only one of which it is in reality applicable. One of these is vesicular 
emphysema, which is dependent on dilatation or coalescence of the pul- 
monary air-cells, without any escape of air into the connective tissue of 
the lung, and which would, therefore, be more correctly called rarefaction 
of iunf/-tis.me. The use of the term vesicular emphysema is, however, so 
universal and long-establi.shed, that it does not seem desirable to discard 
it. The other variety is interlobular or true emphysema, in which the air 
escapes from some point into the connective tissue of the lung, and dis- 
sects its way between the lobules and under the pleura. 

In vesicular emphysema the portions of lung usually worst affected are 
the apex and the anterior border; it may, indeed, be limited to these 
parts, or may be present, in varying degrees of intensity, along the biise 
and even over the entire surface of the organ. Usually it is present in 
both lungs simultaneously, though often much more highly developed on 
one side than the other. 

The dilatation of the vesicles causes marked enlargement of the part 
affected, and when both lungs are K*riously involved, thoy jtroject for- 
wards, occupying the mediastinal space, with their ant^-rior borders ch>sely 
approaching each other. The emphysematous portions do not collapse 
when the thorax is of)ened ; they are pale, dry, and bloodless, and, when 
pressed with the finger, afford a .%oft, doughy feeling, with but an impt-rfect 



214 EMPHYSEMA. 

sense of crepitatioD. On examining the surface carefully, the dilated vesi- 
cles are clearly visible, forming clear, usually round spaces as large as a 
pin's head or a millet-seed. The effect of this distension upon the sur- 
rounding viscera and upon the shape of the thorax are the same in kind, 
though not so great in degree, as are met with in the adult. The dis- 
tended anterior portion of the left lung covers more of the heart than 
normal, and tends to depress this organ downwards and to the right. In 
the same way when extensive emphysema of the right lung is present, the 
liver is usually depressed. If both lungs are affected with marked and 
diffuse emphysema, the thorax is considerably distended, the curve of the 
ribs is increased, while they are elevated so that their course becomes more 
horizontal, and the thorax becomes shorter, deeper in its antero-posterior 
diameter, and more rounded. 

The other variety of emphysema — really the only one which strictly 
merits the name in its usual intention — is the interlobular. Here the air 
makes its escape from a rupture of some air-vesicle or minute bronchiole 
into the connective tissue of the lung, and then readily makes its way 
along the bronchial tubes between the lobules so as to reach the surface of 
the lung. Here it presents itself in the form of minute bubbles of air, of 
rounded or elongated form, easily recognized by their paleness and trans- 
parency, usually arranged in irregular, curving and branching lines, and 
which can be proved to be in the interstices of the lobules by the fact that 
they can readily be pressed by the finger from one place to another, or 
forced to coalesce. When these little bubbles are thickly crowded together 
they produce an appearance well compared by Rokitansky to froth. Asso- 
ciated with them are often found larger bullae, where the air has separated 
the pleura from the surface of the lung; these form flattish, convex prom- 
inences above the surrounding surface, and are freely movable. It will be 
understood that in interlobular emphysema of the lungs, the size of the 
organ is comparatively little affected, and consequently that little or no 
influence is exerted by it upon adjacent viscera or upon the shape of the 
thorax. This condition is comparatively rare, and is not usually associated 
with marked vesicular emphysema; indeed, the anatomical relations of 
the two forms are not clearly understood. In cases where the pleura is 
stripped off from the lung over a considerable space, the membrane may 
be ruptured and air escape into the pleural cavity, constituting pneumo- 
thorax, examples of which accident will be found in our article on this 
latter affection. In other cases, the air makes its way along beneath the 
pleura to the root of the lung, or by penetrating into the substance of the 
organ, and following up the divisions of the bronchi, it reaches the same 
point. It may then pass into the mediastinal spaces, where the loose con- 
nective tissue becomes highly emphysematous, so as to present numerous 
large vesicles with delicate walls, altogether resembling the appearances 
seen in animals in the slaughter-house. From the mediastinum the air 
readily passes upwards into the connective tissue of the neck, where it may 
first produce a crepitant swelling in the suprasternal, supraclavicular, or 
inframaxillary regions ; and may even extend thence over the surface of 
the trunk and extremities so as to produce general emphysema. 



ANATOMICAL APPEARANCES. 215 

In the following interesting ease, wliioh has already appeared in print,' 
the subcutaneous emphysema did not extend below the clavicle. The 
minute perforation on the anterior surface of the upper lobe. wi\s perhaj)s 
due to the inflation of the lungs at the time of the examination, or may 
have occurred just before death. It would certainly have led to pneumo- 
thorax, had it been earlier present : 

Case. — Acuie Miliary Tuhercxilosis : Cough and Dysjmaa : Cervical Emphysema — 
Interlobular Emphysema — Interlobular Emphysema with Perforation of the Pleura : 
Emphysema of Mrtliastinum and Neck. — John F. was born •f a stout, hearty ytuing 
woman, 17 years of age, who nursed him ; and he seemed to thrive until eii:jlit days 
before his death, which took place January 24tii, 1868, at the age of four months. 
The symptoms during his sickness were dyspnoea, occasional dry, hacking cough, 
and am>rexia. A few days before his death subcutaneous emphysema made its 
appearance over the lower part of the neck in front, spreading over both sides, and 
altering the entire contour of the neck, but not descending below the clavicles. 
The post-mortem examination was made fifteen hours after death. 

The head was not examined. The subcutaneous emphysema persisted as above 
described. 

On removing the sternum, the mediastinal spaces were found much distended 
with air, the meshes of the connective tissue in some spots forming vesicles more 
than one inch in diameter, and sugsresting forcibly the appearances often seen in 
animals in the slaughter-house. The emphysema extended up along the trachea 
and larynx, and to a considerable distance on either side of the neck. There was 
not a trace of decomposition of the tissues. The lungs collapsed but slightly ; the 
posterior portions were deeply congested, purplish, and almost non-crepitant, but 
expanded almost fully on inflation. There was neither pneumothorax nor pleuritic 
effu>ion or adhesions. The larynx, trachea, and lungs were removed, and inflated 
under water, when air was found to escape from the right lung in two places — on 
the anterior face of the upper lobe, and on the inner surface of the apex. On ex- 
amining the rupture of the anterior surface of the upper lobe, the opening was 
found to be very small, and to be seated in the midst of a spot where the pleura 
was separated from the lung so as to form a large vesicle. There were other smaller 
pearl-like vesicles studding the surface of the lung. The apex was the seat of 
numerous miliary tubercles, both in the substjince of the lung and immediately 
beneath the pleura. At one point on its inner aspect there was such a subpleural 
deposit, half an inch in diameter, which had undergone cheesy change, and in the 
centre of which there was an ulcerated opening in the pleura. The escape of air 
through this perforation was prevented by the close apposition of a tuberculous 
bronchial gland, about half an inch in diameter, which lay immediately on the 
right bronchus. The other bronchial glands, especially on the right side, were also 
tuberculous. The left lung presented no perforation of the pleura. At several 
points, especially along the anterior edge of the lung, there were large emphysema- 
tous bullae, one inch long by half an inch wide, and in the neighborhood were 
numerous smaller vesicles of the same nature. On incising the lung near these, 
small clusters of gray miliary tubercles were found. Miliary tubercles were also 
found on the peritoneal investment of the liver and spleen, and in the substance of 
these organs and of the mesenteric glands. There were small irregular ulcers in 
the lower part of the ileum, and numerous small yellowish submucous deposits in 
the cjecum. 

Causes. — Although the vesicular and interlobular forms of emphysema 

' W. Pepper, On rome Ca»e8 of Emphysema of the Neck. Philada. Med. Timec, 
August 1, 1872. 



216 EMPHYSEMA. 

are anatomically quite distinct, they may advantageously be considered in 
connection with each other as regards the mode of their development. 

Age. — Vesicular emphysema, though a frequent sequel of acute thoracic 
diseases in children, cannot be regarded as a disease of childhood in the 
same sense as the interlobular form. It is true that the delicacy of the 
walls of the air-vesicles during early life would seem to favor the occurrence 
of dilatation, but experience shows that it does not favor the development 
of emphysema nearly so strongly as does the gradual degeneration and 
weakening of the walls of the air-vesicles which comes on in advanced 
years. 

Interlobular emphysema, on the other hand, is much more frequent in 
children, and reaches degrees of severity which are scarcely found in later 
life. So, too, the occurrence of subcutaneous emphysema, in consequence 
of the rupture of some minute bronchiole or air-vesicle, with the produc- 
tion of subpleural and then mediastinal emphysema, is an accident almost 
limited to early childhood, since of the recorded cases (about 25) in which 
it has occurred, four-fifths (20) have been observed in young children. 
Of these 20 cases of " general emphysema in children," to employ Roger's 
term^ (of which 19 were collected by him, and 1 subsequently published 
by one of ourselves),^ 6 occurred under the age of 2 years, 10 between 2 
and 4, and only 4 between 10 and 15 years of age. 

Previous Diseases. — In children, emphysema occurs as a sequel to some 
other disease, pulmonary or laryngeal. The affections which most strongly 
predispose to it are hooping-cough, the bronchitis of measles, simple bron- 
chitis, pneumonia, and pseudo-membranous croup. Of all these, hooping- 
cough is by far the most fruitful cause. It will be observed that the dis- 
eases named present the common symptom of severe cough, often attended 
with impediment to the escape of air, either from spasm of the air-passages, 
or accumulation of secretion in the bronchi, or mechanical obstruction of 
the larynx by false membrane. 

Mechanism or Mode of Production. — The way in which pulmonary em- 
physema is developed has been made the subject of frequent and conflict- 
ing speculation. Of the two chief theories which have been advanced in 
explanation, one (the inspiratory) regards the overdistension of the vesicles 
as the result of the excessive operation of the forces concerned in inspira- 
tion ; the other (the expiratory) explains it as caused by violent but im- 
peded expiratory efforts. The inspiratory theory is still upheld by some 
eminent writers, but clinical observation is leading to its abandonment. 
In its original form as advanced by Laennec, it was based upon the erro- 
neous notion that the forces of inspiration are greater than those of expi- 
ration, and that consequently emphysema might result from mere exces- 
sive inflation of the lungs. This has, however, been universally abandoned 
as of general application, since the discovery of the important fact that in 
forcible breathing the power of expiration is considerably (at least one- 
third) greater than that of inspiration ; though it is probable that in some 

1 Henri Roger, Archives de Medecine, 5eme ed., tome xx, pp. 129, 288, 403. 

2 W. Pepper [loc. ante cit.). 



MECHANISM OR MODE OF PRODUCTION. 217 

morbid conditions of the pulmonary tissues, violent inspiration may of 
itself be capable of producing emphysematous distension of the air-vesicles. 
The form of the inspiratory theory, which is still retained by some 
authorities, is based upon modifications introduced by Dr. William Gaird- 
ner, and is an expansion of the idea that if certain portions of the lungs 
are, from collapse or other cause, incapable of expansion, the atmospheric 
pressure will determine excessive dilatation of the remaining portions, in 
order to prevent the occurrence of a vacuum as the thoracic walls expand. 
There are, however, such grave objections to this theory, which, it will be 
observed, rests upon the supposition that the expansion of the thorax and 
the amount of air inspired remain at the normal point, although portions 
of the lungs are collapsed or otherwise rendered unable to expand, that we 
are strongly inclined to regard the expiratory theory as the only one capa- 
ble of general clinical application. We owe to Sir William Jenner chiefly 
the satisfactory refutation of the principal argument which was formerly 
brought against this latter theory, that "the expiratory act is mechani- 
cally incapable of producing distension of the lung, or of any part of it. 
The act of expiration tends entirely towards emptying the air- vesicles by 
the uniform pres^sure of the external parietes of the thorax upon the whole 
pulmonary surface ; and even when the air-vesicles are maintained at their 
maximum or normal state of fulness by a closed glottis, any further dis- 
tension of them is as much out of the question as would be the further dis- 
tension of a bladder, blown up and tied at its neck, by hydrostatic or 
equalized pressure applied to its entire external surface" (Gairdner). A 
little consideration of the anatomical relations of the lungs to the thorax 
shows the falsity of this argument. The different portions of the lungs are 
in contact with surfaces and tissues of very different degrees of resisting 
power, and while the entire postero-lateral portions are supported by the 
unyielding ribs, the apices are covered only by soft tissues, and the ante- 
rior borders of the lungs are supported externally by the comparatively 
yielding costal cartilages, while centrally they are able to encroach con- 
siderably uix>n the tissuas of the mediastinal spaces. In ordinary free ex- 
piration the air is forced out of the lungs by a pressure so moderate and 
gradual that even the weakest parts of the thoracic walls are sufficiently 
firm to maintain it. But when the expiratory efforts become more violent, 
the air is pressed with great force from the central, basic, and lateral por- 
tions by the ascent of the diaphragm and the compression of the thorax, 
while the outward current from the apices and anterior margins is com- 
paratively feeble. If, therefore, from any cause the normal relation be- 
tween the volume of the expiratory current of air and the calibre of the 
large bronchi be di.sturbed, the portion of air which cannot escape will be 
driven violently into the apices and anterior margins, not only overcoming 
the outward current of air proceeding from those |>ortions of the lungs, but 
producing an excessive degree of distension of their air-cells. The strong- 
est possible confirmation of the truth of this view is to be found in the fact 
that emphysema, both of the vesicular and interlobular form, is found to 
be develoj)ed in the various parts of the lungs in precise correspondence 
with the degree in which they lack firm external supixjrt. 



218 EMPHYSEMA. 

There are two ways in which a disturbauce of the above relations may- 
be effected : either by an obstruction in the air-passages, which prevents 
the free escape of the air, or by the expiratory act being so sudden and 
violent that the volume of air hurriedly forced from the air-vesicles is too 
great to pass freely through the primary bronchi. Instances of this latter 
condition are familiar to all in violent fits of coughing, during which, 
even when there is no obstruction in the air-passages, the degree of disten- 
sion of the apices may be appreciated by the bulging of the supraclavicu- 
lar tissues. The full pulmonary resonance, which is elicited by percussion 
of this bulging, proves conclusively that it is due to distension of the 
apex ; and it is therefore easily understood how the repeated operation of 
such a cause may gradually lead to the development of vesicular emphy- 
sema, or how in an abrupt, violent, and prolonged expiratory effort, at- 
tending a fit of coughing, there may be a rupture of some minute bron- 
chiole or air-vesicle, followed by interlobular emphysema. Undoubtedly, 
also, the mechanical effects of such overdistension will be greatly enhanced 
by morbid conditions of the lung-tissue which weaken its elasticity, such 
as are present in severe bronchitis, especially when associated with consti- 
tutional diseases. Far more frequently, too, there is associated some cause 
of partial obstruction to the escape of air, such as the spasmodic contrac- 
tion of the air-passages in hooping-cough, the presence of layers of false 
membrane in the larynx or trachea, or thickening of the bronchial mucous 
membrane with plugs of viscid tenacious mucus in the tubes. 

It is very possible, also, that in some cases interlobular emphysema may 
be caused by the implication of a minute bronchiole in the progress of the 
softening of some spot of diseased tissue, so that the air might find en- 
trance to the interstitial connective tissue without any mechanical cause of 
overdistension and rupture of air-vesicles. Thus in the case reported 
above (p. 214) there was certainly a very close connection between the 
position of the patches of tuberculous deposit and the bullae of subpleural 
emphysema, so much so that we cannot doubt that the escape of air was 
in some way favored by their presence. In another case also, where inter- 
lobular and subpleural emphysema, followed by pneumothorax, occurred, 
and which is reported at length in our article on this latter affection (p. 
250), it seemed to us that probably the softening of superficial circum- 
scribed patches of pneumonia had opened into minute bronchioles, and 
thus allowed the escape of air. 

Symptoms. — We have already seen that in young children emphysema 
occurs usually in an acute form in connection with some acute disease of 
the lungs. Although, therefore, its presence may be suspected in such 
cases where violent paroxysms of cough have occurred, associated with 
prolonged, severe dyspnoea, there are scarcely any physical signs by which 
its existence can be determined. The percussion-resonance will continue 
clear, or even become somewhat exaggerated, and this fact of the absence 
of any dulness (due to pneumonia, collapse, or pleural effusion), in a case 
of hooping-cough or bronchitis, when severe cough has occurred with un- 
usually extreme dyspnoea, is of diagnostic value. The respiratory murmur 
undergoes no immediate change in its character, and it is not possible, 



SYMPTOMS. 219 

owing to the violent and rapid respiratory efforts of the child, to detect 
any diminution in the force of the murmur. Expiration in such cases is, 
however, often already prolonged and laborious. 

The development of acute vesicular or interlobular emphysema, then, 
is suspected rather on account of the character of the disease from which 
the child is sutiering than from any distinct substantive symptoms; of these 
conditions. Exception is to be made, however, of the rare cases, in which 
suddenly, in the course of an acute pulmonary disease, a swelling is noticed 
at some part of the neck, or in the subclavicular space, which on palpa- 
tion is found to crepitate. This may be regarded as, in all probability, 
connected with extensive interlobular emphysema. The other chief cause 
of such subcutaneous emphysema is perforation of the larynx or trachea, 
and the previous symptoms will enable us to exclude this rare condition 
without difficulty. 

In other ci\ses, however, vesicular emphysema in children assumes the 
chronic form, more usually found in adults, and will then be attended 
with the well-known symptoms of this affection. At times, it occurs evi- 
dently as a sequel to some acute pulmonary disease, in the course of which 
it has been developed in the manner above described, and after the original 
lisease has passed away, it persists, either owing to original weakness of 
the lung-tissue, or to the extreme degree of the dilatation of the air-vesicles. 
At other times, it is met with as a purely chronic affection, which may 
begin in early childhood, and gradually increase until the disease is fully 
developed. In such patients there is probably some congenital weakness 
and tendency to degeneration of the pulmonary tissues. It is not unfre- 
quently found that there are also evidences of rachitic disease of the ribs 
in such caifes. 

Children with chronic emphysema present various degrees of habitual 
dyspncea, which is always readily increased by exertion. They are very 
-ubjeet to attacks of bronchitis, during which the breathing is much em- 
barrassed and wheezing, the chest is full of sonorous and sibilant rales, 
and the cough occurs in severe paroxysms without much exj^ectoration. 
During these attacks, not unfrequently the child suffers at night from vio- 
lent paroxysms of spasmodic asthma. Indeed, it may happen that attacks 
of asthma will be induced in emphysematous children by the most trifling 
cau.-es, such as changes of weather, indigestion, and the like. The attacks 
of bronchitis vary greatly in different cases in their relation to season and 
temperature ; in some they occur almost exclusively during the damp, cold 
weather of fall and winter, while in others they are most frecpient and 
-evere during summer and sjiring, and the child finds more relief during 
cold weather. 

The cough varic:^ much in its intensity and character. During the 
attacks of bronchitis it is usually very severe, occurring in long spells, at 
fir>t with a little mucous expectoration, and later, as the attack passes 
over, with more abundant muco-purulent sputa. In the intervals of the 
attacks it may continue as an occasional dry and rather wheezing cough, 
or it may be more troublesome on account of a certain degree of chronic 
bronchitis being always present, or finally it may altogether subside. After 



220 EMPHYSEMA. 

the disease has lasted a considerable time, however, cough may become 
persistent, occurring most severely at certain periods of the day, and 
attended with a considerable quantity of muco-purulent expectoration. In 
such cases, when emphysema is conjoined w^th chronic bronchitis, the sus- 
picion is apt to arise that the child is suffering from phthisis, and the posi- 
tive determination of the diagnosis may indeed be attended with some 
difficulty. The reader is also referred to the remarks made in this con- 
nection on the subject of chronic bronchitis (see p. 200). 

In young children under the age of 5 or 6 years, emphysema rarely 
reaches so great a degree, or persists for so long a time as to induce 
marked changes in the shape of the thorax, or to seriously affect their 
nutrition. In children somewhat older, however, when the disease is 
more severe and chronic, it may be attended with most of the symptoms 
familiar in the adult. The appearance of such children is apt to be frail 
and delicate, their muscular system develops slowly, and they become so 
readily fatigued and out of breath that they avoid play or much exer- 
cise. The shape of the thorax becomes gradually altered ; the shoulders 
grow high and rounded, and the chest is prominent and distended in its 
upper part, while owing to imperfect expansion of the lower lobes, there 
may be perceptible retraction of the base of the thorax in front, or even 
a marked depression around the entire base of the chest. Of course, this 
is likely to occur to a more marked degree if the emphysema is associated 
with rickets. 

The physical signs vary greatly with the extent and degree of the em- 
physema. In cases where it is limited to small areas of the lungs, scarcely 
any physical sign can be detected ; but in partial and more severe forms, 
the following phenomena can be observed : The respiratory movements 
are restricted especially in the way of expansion ; and during inspiration 
the movement is chiefly one of elevation effected by overaction of the 
upper respiratory muscles, and attended with an evident deepening of the 
depression around the base of the chest. The percussion-resonance is very 
full and clear, or even tympanitic, though owing to the marked resonance 
normal in children, it is difficult to determine the degree of its exaggera- 
tion. There maybe associated some impairment of resonance over the 
retracted base of the thorax, and especially posteriorly, where there may 
be congestion of the lung with accumulation of secretion in the air-pas- 
sages, due to the coexisting bronchitis. The respiratory murmur is weak- 
ened, though rarely to the degree noticed in adults ; the expiratory mur- 
mur is decidedly prolonged and frequently wheezing. Both inspiration 
and expiration are apt to be accompanied with sonorous and sibilant rales. 
These, and especially the sonorous rales, are most markedly developed 
over the posterior parts of the lungs, near the larger bronchi. In some 
cases, moist rales may also be heard over the postero-inferior parts of both 
lungs, owing to the presence of an unusualfy large quantity of secretion 
in the smaller bronchial tubes. During one of the acute aggravations of 
the bronchitis, attended with nervous asthma, to which we have above al- 
luded as being so frequent in such patients, a dry sibilant rale, distributed 



SYMPTOMS. 221 

over the entire thorax, is ofteu the only sound heard accompanying: the 
lahored respiration. 

In marked cases, there will also be impairment of the resonance and 
fremitus of the voice, couirh or cry. The apex-beat of the heart may be 
concealed by the distended king, and the area of cardiac dulness is dimin- 
ished. As before said, the alterations of the shape of the thorax and the 
marked physical signs now described are very rarely observed in children 
under the age of 5 or 6 years, and become more constant and more marked 
at later periods of childhood. 

Case. — A., aet. 8 years, came under observation in the fall of 1873. Tho flnnjrli- 
tor of healthy parent-s, she was nursed until the asreof 2 years. She suffered much 
from occasional diarrhoea for the first three years of life, but then improved in this 
respect. She cut her teeth without difficulty, and as rapidly as usual ; bejran to 
walk at usual age. Has always perspired profusely atniirht, especially about neck 
find head, and when an infant was very troublesome from constantly kickinjx off 
the bedclothes at nicjht. There was no muscular soreness. 

At the age of 4 years she had a severe attack of spasmodic croup, and since then 
has been subject to frequent attacks of bronchitis, often associated with asthma. 
At first, there were only a few attacks each year, but for the past year thoy have 
followed each other with scarcely any intermission. She always suffers more dur- 
inc summer than in winter, and has found relief on several occasions by spondinsj 
a fow weeks durint; the summer at the seashore. The attacks usually be<rin as a 
simple catarrh, with sneezinc: for a couple of days, followed then by whopzins: 
cou£:h, shortness of breath, and nocturnal attacks of asthma. There is habitually 
dyspncpa on exertion, and the child has grown to care little for play, and to prefer 
staying quietly indoors. Lately there has been pr^rsistent and severe cousrh, with 
muco-purulent expectoration, feverishness, loss of appetite and strenirth. One 
year ago alteration in the shape of the chest was noticed. She was very much 
benefited last fall (when she was seen once by us) by the use of muriate of ammo- 
nia in full doses, with a mixture of quinia and arsenic; but after its cessation .che 
has had a return of her troublesome symptoms. At present she is a rather tall 
and delieate-looking child, with hiijh roiinded shoulders. The upper part of tho 
thorax, from above the clavicle down to the fourth rib, is di'^tended. Bolow that 
level there is retraction of the anterior chest-walls, and on passinc: the finijer 
parallel to the sternum thore is a quite marked croove about one inch from each 
side of that bone, caused by incurvation of tf^e ribs alonij that line. The expan- 
sion of the chest is limited. The apex-beat of the heart is at the sixth rib nearly 
2" below line of nipple, beintr apparently somewhat depressed. Percussion-reso- 
nance is exaggerated and almost tympanitic over supra- and infra-davicnlur 
spaces, while over the retracted portions of the chest it is .slichtly impaired. The 
vesicular murmur is impaired, and over the superior part of the chest expiration 
is evidently prolonged. No rales are heard anteriorly, but posteriorly, at tho base, 
and especially about the roota of the lungs, snoring rales are heard. 

The case appears to be on-* of emphysema of the upper part* of the lungs, asso- 
ciated with deformity of the chest, partly due to ricket«, partly to the emphy- 
sematous distension of the lungs, and attended with a varying degree of chronic 
bronchitis, with a tendency to spasmodic asthma. 

She was ordered careful diet and clothing ; salt baths daily ; regulated gymastic 
exercises with her arms; and th» following medicines: 

B. Pot&ss. lodid., . gr. ij. 

PoU.«. Bromidi, gr v. 

Syr. Ferri lodidi gtt. v. 

Syr. Tolutoni, trtt. xxv. 

Aquae, C*^*"- 

Ft. Bol. S. t. d. 



222 EMPHYSEMA. 

The use of this was followed by improvement in appetite and strength, and by a 
marked diminution in the frequency and severity of the asthmathic attacks. As, 
however, the cough continued quite severe, with abundant loose mucous rales 
throughout the chest, the treatment was changed to the following : 

R. Syr. Phosphat. Comp., f^ij, 

Elix. Calisayae, 

Aquae, aa f^j. — M. 

Dose. Two teaspoonfuls in water before meals. 

And to relieve the cough : 

R. Ammonise Muriatis, grs. Ixxij. 

Syr. Senegae, 



Tr. Hyoscyami, . 

Ext. Pruni Virg. Fluid. 

Syr. Zingiberis, . 



f5ss. 
f^iss. 
f3ss. 
q. s. adf^iij. — M. 



Dose. A teaspoonful in water three or four times in twenty-four hours, according 
to the severity of the cough. 

Under the use of these remedies, her improvement was rapid and continuous, 
and for the past year and a half there has been scarcely any tendency to bronchitic 
attacks. Her frame has developed, and the shape of the thorax has improved so as 
to confirm the evidence of the physical signs that the emphysema is gradually 
disappearing. 

Diagnosis. — In regard to the detection of the acute form of emphysema 
at the time of its occurrence, we have already shown that there are no 
signs sufficiently distinctive, and that if any unusual severity or persistency 
of dyspnoea rouses'the suspicion, we may only assume its presence in con- 
sequence of the great frequency with which it is developed in certain 
diseases. 

This is even more true with regard to the interlobular than the vesicular 
form, except when the sudden appearance of subcutaneous emphysema 
proves its existence. 

If, however, emphysema becomes firmly established, and persists, it be- 
comes attended with the well-marked symptoms already described, and 
there are then scarcely any conditions with which it can be confounded. 
In almost all cases, there is associated bronchitis, either in the form of re- 
peated acute attacks, or, more frequently, of a chronic form of varying de- 
grees of intensity. It is therefore necessary to guard against overlooking 
the evidences of emphysema, and considering such cases as simple forms of 
bronchitis. In cases where emphysema of long standing is accompanied 
by severe and chronic bronchitis, it may be confounded with phthisis. 
Apart, however, from the fact that chronic phthisis is rare in childhood, a 
careful study of the history of the case, and of the physical signs, will en- 
able us to avoid this error. 

Prognosis. — Only in extreme cases of emphysema in children is the 
prognosis so unfavorable as in this condition in adults. In many cases 
where there can be no reasonable doubt that it exists to a considerable ex- 
tent, the luDg-tissue regains its contractility soon after the exciting cause 
of the emphysema has been removed, and all evidences of its existence 
gradually disappear. Even in more protracted cases, when the disease 



41 



PROiiNOSIS — TREATMENT. 223 

persists for some years, and leads to deformity of the thorax, there is 
ground for hope that, under the influence of the developing constitution 
and frame, and sustained judicious treatment, considerable relief will he 
obtained. This is equally true in regard to the tendency to attacks of 
nervous asthma, which is so frequently associated with emphysema, as it is 
true of its other symptoms. Children, who, at an early age, sutter severely 
with such attacks even from the slightest causes, are frequently seen to en- 
tirely outgrow the distressing tendency, and to bear any change of climate 
or vicissitude of weather without inconvenience. 

The prognosis of mediastinal and subcutaneous emphysema dependent 
upon the interlobular form, is of course controlled entirely by the nature 
of the primary disease. It undoubtedly of itself aggravates the dyspna^a 
caused by the original pulmonary disease, but still very rarely reaches so 
extreme a degree as to endanger life. It must be borne in mind, however, 
that it is very frequently associated with pre-existing lesions of the lungs, 
which, either from their character or their extent, are almost necessarily 
fatal. Thus, of the 20 cases before referred to as on record, in only 4 has 
this accident been followed by recovery. It must, therefore, be regarded 
merely as a serious complication, but one which would not justify an al- 
together unfavorable prognosis in an otherwise curable condition. 

Treatment. — The treatment of cases of acute pulmonary disease, in 
the course of which it is suspected that emphysema has occurred, cannot 
be much modified on account of this complication. As it is, however, 
closely dependent, in such cases, upon the frequent and violent cough, the 
most important indication is to allay this by suitable antispasmodics and 
sedatives. At the same time, as the increased dyspnea which is caused 
by the development of the emphysema must seriously add to the exhaus- 
tion of the patient, the utmost care must be exerted to sustain the vital 
powers, and to discard every depressing element from the treatment. 

The same remarks, which are used above with special reference to vesic- 
ular emphysema, apply with equal force to the interlobular form when it 
becomes complicated with mediastinal and subcutaneous emphysema. Tiie 
only chance of recovery in such cases, is to be found in sedulously support- 
ing the system until the primary disease (if of a curable nature) has passed 
away, and the effused air has been gradually absorbed. This absorption 
may be, to some extent, hastened by gentle frictions on the em|)hyscmatous 
parts with the hand. In cases where the extent of the external emi>hysema 
is such as to threaten life, minute punctures may be made in the distended 
skin, and the escape of the air favored by gentle pressure with the hands 
towards the point of puncture. 

The most important field for medical treatment is, however, to be found 
in those cases where emphysema, whether acute or not in its incipicncy, 
has passed into a chronic or persistent form. The indications for treat- 
ment which here present themselves, are mainly to relieve the chronic 
bronchitis, which is almost invariably asw>ciated with emphysema, if it 
has not been its ehiefcau.se; to eradicate any rachitic tendency which 
often coexists and, .so far as possible, to counteract its result-; U) guard 
against and relieve the acute attacks of bronchitis often accompanied with 



224 EMPHYSEMA. 

nervous asthma, from which such children suffer ; and finally to favor, so 
far as lies in our power, the restoration of the dilated lung-tissue to its 
normal condition. 

There are several considerations of a general character, which will be 
found to have an important bearing upon these requirements. 

Change of climate, when it can be judiciously made, is often attended 
with excellent results, particularly as regards the bronchitic irritation and 
the attacks of asthma. We have known children who suffered most se- 
verely from these conditions, which were aggravated by any trivial causes 
so long as they remained in their native place, but who on removal to other 
climates, received marked relief and gradually outgrew the disease. It is 
not at all necessary that this change should be to a distant spot ; often the 
most convenient, dry, elevated, inland locality will answer excellently. 

The clothing of such children should be carefully studied and regulated. 
Without being so heavy as to oppress, it must be at all times warm enough 
to thoroughly protect; and at the same time there should be a suit of flannel 
or silk (consisting of an undershirt with long sleeves, and long drawers 
coming down to the ankles), of varying thickness to suit the season, worn 
throughout the year, to protect the surface of the body from the chilling 
effects of sudden vicissitudes of temperature. 

As further means to secure activity of the circulation and function of 
the skin, the use of salt baths (of a temperature to suit the season), and 
followed by brisk rubbing with a coarse towel, are to be recommended. 

In no condition of the system is the use of gymnastic exercise more to 
be insisted upon. We should select those exercises with light dumb-bells 
or Indian clubs, which will tend to strengthen the muscles of respiration, 
expand the lower portions of the chest, which, as we have already pointed 
out, are apt to be retracted, with some incurvation of the ribs, from the co- 
existence of rickets at an earlier age. As children in whom emphysema 
assumes the chronic form are usually over the age of 6 or 7 years, such 
exercises can be readily carried out 

Very recently several forms of apparatus have been devised for enabling 
the respiration of air of different degrees of condensation or rarefaction 
to be employed with accuracy. The one which we have ourselves em- 
ployed is known as Waldenburg's apparatus, having been designed by 
this eminent physician, who also has been chiefly concerned in introduc- 
ing this new method of treatment. In the case of emphysema, the patient 
is caused to expire into a receiver containing rarefied air. It is evident 
that this will exert an increased suction power on the air in the lungs, and 
thus will favor the emptying of the air-vesicles and the contraction of the 
chest to its normal limits. Undoubtedly in children, this method, which 
we have used with good results in adults, should be employed with caution ; 
but it is especially in young persons, when the elasticity of the ribs and of 
the lung-tissue is greater, that the most positive effect may be hoped for in 
causing a restoration of the chest to its normal size. 

The selection of the diet should be made with care. It will often be 
found that all the symptoms are aggravated by any digestive disturb- 
ance, and we have seen, as is indeed frequently the case in emphysema of 



TREATMENT. 225 

adults, violent paroxysms of nervous asthma induced by indigestion. As 
the digestion in such children is apt to be weak, this point requires the 
greater care. 

As regards medication, the most important remedies are such as will 
affect the constitution favorably. 

We should recommend the use of cod-liver oil in properly graduated 
doses, and, especially where there are evidences of rachitic disease, the 
compound syrup of the phosphate or the lacto-phosphate of lime may be 
advantageously associated in the form of emulsion. If iron is not thus 
administered in the form of the phosphate, the oil may be given alone, 
and iron should be taken separately in some other combination, as in the 
following: 

R. — Potassii Bromidi, ^\j. 

PotAssii lodidi i;r. xlviij. 

Syr. Ferri lodidi, f^ij 

Syr. Tolutani, f :5vj. 

Aquae, f^ij. 

Ft. sol. S. — A teaspoonful thrice daily in a little water. 

The dose here directed is for a child of about 8 years of age. 

"We have also found the prolonged use of arsenic for it5 constitutional 
effects of much value in some cases. 

Cough should be relieved, so far as possible, without the use of opiates 
and nauseating expectorants. Among the drugs which we have found 
most useful in controlling it, as well as in relieving the chronic bronciiitis 
upon which it usually depends, are the iodide of potassium, which may 
be advantageously combined with the potassium bromide, as in the above 
prescription, the bromide of ammonium, and the muriate of ammonia. 
If the cough be very troublesome, especially at night, tincture of hyos- 
cyamus and minute doses of morphia may be occasionally associated. It 
may, however, become necessary to substitute for these, or to combine 
with them, other alterative and stimulant expectorants, such as .seneka or 
copaiba. 

The useof quinia,and, at times, of strychnia with it, is indicated through- 
out a large part of the treatment for the u.seful influence of these drugs 
upon the digestion and general nutrition, and especially upon the tonicity 
of the muscular system. 

The acute attack.*? of nervous asthma which are apt to occur from time to 
time must be relieved at the moment by the prompt use of relaxing emetics, 
hot rau.'*tard- water foot-baths, the inhalation of ether or of the smoke of 
>tramoniura cigarettes. The frequency of the.*<c di.strcJs'^ing attack.^ will, 
however, be greatly influenced by the persistent employment of the gene- 
ral treatment above sketched. 

Finally, it must not be forgotten that despite the obstinacy and severity 
•f the eymptoras of emphysema in .'^jme ca.'*€J<, and the positive alterations 
'*f the .shape of the thorax, there i.«* always reason to hope that if we can 
-ucceed in removing the element of chronic broDchitis, and in favoring the 

15 



226 PLEURISY. 

expansion of the lower lobes of the lungs, so as in these ways to relieve 
the strain upon the upper portions of the organs, the distended vesicles 
^vill gradually regain their elasticity, and as the thorax enlarges with ad- 
vancing years, all symptoms of the disease will pass away. 



ARTICLE V. 



PLEURISY. 



Definition; Frequency; Forms. — Pleurisy consists in inflammation 
of the pleural serous membrane. 

Idiopathic pleurisy is a rare disease under five years of age, and especi- 
ally in the first and second years of life. After the age of five years it 
becomes more frequent. We have met with 28 cases of pleurisy, of which 
we have kept notes. Of the 28, 26 were idiopathic, and 2 secondary ; one 
of the latter occurring during hooping-cough, and the other being accom- 
panied by pneumonia, though the pleurisy was the predominant disease. 
Secondary pleurisy, on the contrary, or that which occurs in the course of 
other diseases, is common at all ages. M. Bouchut met with it in 23 out 
of 68 autopsies of new-born and suckling children. Of the 23, 9 accompa- 
nied acute pneumonia, 6 tubercular pneumonia, 5 entero-colitis, and 3 dif- 
ferent other diseases. This form of the affection is rarely detected during 
life, being masked by the concomitant malady.^ 

We shall describe two forms of the disease, the acute and chronic. 

Predisposing Causes. — As to the influence of age, it has already been 
stated that idiopathic pleurisy is rare between birth and five years of age. 
It is certainly rare, during those years, in comparison with pneumonia, and 
especially with bronchitis, for we find that while we have met with but 15 
cases of pleurisy of all kinds under five years of age, we have seen 28 of 
pneumonia under that age, and 105 of bronchitis under six years of age. 
Of 28 cases of pleurisy that we have seen, 26 were idiopathic, and of these 
one occurred at the age of three months ; three between 1 and 2 years of 
age; one between 2 and 3 ; four between 3 and 4; eight between 4 and 5 ; 
three between 5 and 6 ; two between 6 and 7 ; three between 7 and 8 ; and 
one between 13 and 14. Of the two secondary cases, one occurred at six 
weeks of age, and one between 4 and 5 years. Secondary pleurisy is said, 
by the best authorities, to be most frequent between one and five years of 
age, being, in this respect, just the contrary of the idiopathic form of the 
disease. 

1 In this as well as in some other places, the figures remain as they were in some 
of the previous editions, although a very much larger number of cases have fallen 
under our observation. But as it has been impossible, owing to the pressure of 
other duties, to make records of any large proportion of them, and as the general 
results have not been materially aflfected, we have allowed the figures to continue 
unchanged in this edition. 



ANATOMICAL LESIONS. 227 

'pleurisy is said to occur more frequently iu boys than girls. Of 26 cases, 
in which we noted the sex, 19 occurred iu boys aud 7 iu girls. The idio- 
pathic form is most apt to occur iu vigorous aud hearty subjects, while the 
chronic and cachectic forms attack those who are feeble aud delicate. It 
is often, as already stated, a secondary affection, occurring particularly 
during pneumonia, and, after that disease, during rheumatism, scarlet 
fever, and Bright's disease. Season is another preilisposing cause. It is 
most common during winter and spring, especially the latter. 

The exciting causes are very obscure in most cases. The ouly ones which 
seem to have been ascertained with any certainty, are exposure to cold 
and sudden changes of weather. It has been said to follow exterual vio- 
lence. In one of the cases that came under our own observation, the child 
had struck the affected side severely against a pointed stick ou the day of 
the attack. 

Anatomical Lesions. — The serous membrane may retain it^ uatural 
characters, or as happens in most instances it may present the different 
appearances indicative of inflammation. These are more or less minute 
and abundant injection and punctuation, aud spots or patches of an ecchy- 
motic appearance, observable particuhirly at the points where the forma- 
tion of false membrane has taken place. Another change produced iu the 
pleura by inflammation is the loss of its natural polish, which is replaced 
by a more or less granular aud rough appearance. In chronic cases it 
becomes whitish or opaline in color, and thickened. It is very rarely soft- 
ened. 

In addition to the lesions of the pleura itself there are various diseased 
products of secretion which require notice. These may be either solid or 
liquid. The solid products are the false membranes which exist so gener- 
ally in all .serous inflammations. They are found both upon the costal and 
pulmonic pleura. In their recent state they are of variable size and thick- 
ness, being in some cases very soft and deposited in small points ; in others, 
more extensive, but thin, like paper; and in others again thicker (one or 
two lines in thicknes^s), firmer, and decomposable into several layers. 
The outer layers are yellow, elastic, and soft, while the inner ones are red, 
more resisting, and marked with vascular arborization. When examined 
some time after their formation, the false membranes are found to have 
been converted into cellular adhesions, which may be either very loose, or 
they may fasten the lung tightly to the costal pleura. The adhesions are 
generally, however, thin, transparent, and in the form of loose bridles. 
After a length of time, the false membranes come to present the api)ear- 
ances of true serous tis^^ue, and like that, are susceptible of inflammation. 

The fluid found iu the pleural cavity usually consists of transparent or 
turbid serum, holding albuminous flocculi in suspension. Sometimes, but 
more rarely, it consists of purulent serum, and still more rarely of pure pus. 
The liquid generally occupies the lowest portion of the thoracic cavity, 
but is sometimes circumscribed at various heights, or between the lobes of 
the lung by abnormal adhesions, or by some part of the lung which Han 
been rendered incompressible by inflammation. 

The lung presents various alterations from ita healthy conditioo. It is 



228 PLEURISY. 

pressed backwards towards its root to a greater or less extent. The tissue 
of the organ is generally found in one of two conditions : either hard, not 
crepitating, impenetrable to the finger, and presenting a smooth surface 
when cut into, a state of things which has been expressed by the term car- 
nification, and which is a mechanical effect of pressure ; or else the lower 
lobe, which is in contact with the fluid, is large, heavy, fleshy, rather hard, 
not so easily penetrable by the finger as in simple hepatization, yielding 
under pressure only a small quantity of blood, and but slightly retracted 
towards the spinal column. The latter condition depends in all proba- 
bility on an effusion w^hich has occurred after, or coincidently with hepa- 
tization. 

In some cases, in which the effusion is but small, or where it has been 
absorbed, the lung is found to be elastic and crepitating. Whatever the 
amount of effusion may be, the lung can always expand to its normal size 
if the fluid be absorbed, unless it has been too firmly bound down by false 
adhesions. 

Pleurisy, whether complicated with pulmonic disease or not, is much the 
most frequently confined to one side. In idiopathic cases, it is more com- 
mon on the right than left side ; when it accompanies pneumonia, it is, on 
the contrary, more common on the left than right. 

Symptoms. — In describing the symptoms, we shall treat first of the 
physical, and then of the rational signs, and of the course of the disease. 
The physical signs are exceedingly important, as they often constitute, 
especially in young children, the only means of recognizing the disease. 
The pleural frictio7i-sound is less important than some other physical signs, 
as it is by no means constantly heard in children under five years of age, 
and only during the absorption of the fluid, as a general rule, in those 
above that age. Bronchial respiration may commonly be detected from an 
early period in the attack. It is however to be carefully distinguished 
from the true, sniffling, superficial bronchial breathing due to pneumonic 
consolidation of the lung. In pleurisy, with effusion, the bronchial respi- 
ration is evidently transmitted from the bronchi of the compressed lung 
and from the trachea. Indeed, it will sometimes be found that, in a case 
where distinct bronchial breathing is heard over the seat of the effusion 
during noisy, hurried breathing, it will be lost and replaced by feeble re- 
spiratory murmur, if the child breathes quietly and without making any 
noise in the throat. At first the bronchial respiration is usually heard 
during inspiration, but afterwards it exists both during inspiration and 
expiration, or in the former alone. In a majority of the cases it is heard 
over the posterior portion of the thorax, and upon one side only. At first 
it is audible over nearly the whole height of the affected side, while later 
in the disease it can be perceived only at the inferior angle of the scapula 
or in the interscapular space. Its duration is variable ; it may disappear 
in a few days, or last for a much longer time. In favorable cases it is 
usually replaced by feeble vesicular respiration, more rarely by friction- 
sound, and sometimes by pure respiration. This sign is almost always 
present at all ages in acute cases, but is often absent in those which are 
slow and tedious. In suckling children it is not constant, but intermits 



SYMPTOMS. 229 

occasionally, so that it may be heard at one and not at the next examina- 
tion. ^Egophouy can rarely be detected in children less than two years 
old. Under that age, there is heard instead of it resonance of the cry, 
especially in the region beneath and on a line with the spine of the scapnla. 
It is intermitting, like the bronchial respiration. In children over two 
years old, jegophony can often be distingnished by careful examination, 
but never, of course, unless the quantity of effusion is considerable. It is 
heard at an early period of the attack, and chiefly in acute cases, and must 
be sought for in the lower portion of the interscajuilar space, and the infe- 
rior dorsal region. It coexists almost invariably with bronchial respira- 
tion, lasts but a short time, disappearing after one, two, three, or four days, 
and it is intermitting. In older children, it is sometimes replaced by 
diffused resonance of the voice, as it is by resonance of the cry in infants. 
In a case that occurred to one of ourselves, in a girl between six and seven 
years old, and in which the disease became chronic, the voice was not 
purely iegophonic, but reedy and quavering, from the fifth to the tenth 
day. After that date the effusion became so great that all sound was 
suppressed. 

Feebleness or absence of the rej^piratory murmur seldom exists at the be- 
ginning of acute cases, but in the subacute or chronic form is generally 
present from the invasion. In the latter class of cases feeble respiration 
is noticed first over the inferior portion of the dorsal region, but as the effu- 
sion increases, it is heard also in the upper and anterior regions, and be- 
comes more and more marked, until at length no sound whatever is audi- 
ble ; the respiratory murmur is suppressed. In acute cases, on the con- 
trary, the absence of the respiratory sound is observed at variable periods 
of the attack; when noticed soon after the invasion, it is generally coinci- 
dent with distant and transmitted bronchial respiration, which, heard at 
first over the whole or the inferior three-fourths of the dorsal region, 
l>ecomes afterwards perceptible only in the interscapular space, or at the 
inferior angle of the scapula, while the respiration is feeble or absent over 
the lower portions of the lung. In acute cases the feeble respiration re- 
mains limited to the dorsal region, and disappears after a few days, — in 
from five to eight, according to our exiK-rience; while in chronic cases it 
extends over a larger surface, and cuntitiiic- for several weeks, or even 
months. 

/'. I yion. — This means of diagnosis is very important in all cases of 
ill. . ~ ;i-^ accompanied by effusion of liquid, unless the quantity be ex- 
cee<ling)y small. When, on the contrary, the inflammation results merely 
in the production of thin fali*e membranes, percussion furnishes no useful 
information. 

Percussion is of no assistance, however, at the moment of invasion, as it 
is not until the [lericKl at which effusion tjikes place that the resonance of 
the thorax begins to be altered. In acute eases, the resonance is generally 
duller than natural, though seldom entirely dull, on the second, third, or 
fourth day. As the effusion augments, the dulness increases over the region 
fxrcupied bv the fluid, until at length all resonance cea.«*es, and the sound 
is perfectly flat. The degree of dulneas can be properly appreciated only 



230 PLEURISY. 

by comparing the two sides together. The degree, extent, and duration of 
this sign will depend, of course, upon that of the effusion. In children, as 
in adults, the sounds afforded by percussson vary with the position of the 
patient, which influence, of course, the situation of the fluid in the pleural 
cavity. 

In regard to the physical signs of pleuro-pneumonia, it may be stated 
that when a pleuritic effusion takes place in a child laboring under pneu- 
monia, it happens, as a general rule, that the bronchial respiration occa- 
sioned by the inflammation of the lung increases in intensity, though in 
some few cases it is diminished or suppressed. MM. Rilliet and Barthez 
lay down the following principle : " That ivhen a pleuritic effusion occurs 
in a child affected luith hepatization of the inferior portion of the lung, all the 
abnormal sounds which were perceptible over the diseased point are consider- 
ably exaggerated, and the sonority disappears.^' 

Inspection of the thorax affords no assistance at the invasion of the 
disease, nor generally in acute cases which last but a short time, and in 
which the amount of effusion is small. When, however, the effusion is 
large, it may be observed, upon close examination, that the movements 
of the affected side during respiration are more limited than those of the 
opposite one, and that the intercostal spaces are more projecting than natu- 
ral, in consequence of distension by the fluid within. At the same time 
mensuration will show that the side on which the effusion exists is larger 
than the other. The difference may amount to one-third or two-thirds of 
an inch. In acute cases in which the quantity of liquid is small, mensu- 
ration will of course show no difference. 

Palpation is an important means of diagnosis, especially in making the 
distinction between pneumonia and pleurisy. In the former disease, the 
vibration of the thoracic walls during either crying or speaking, is aug- 
mented ; whilst in the latter it is diminished, or when the effusion is con- 
siderable, ceases altogether. This sign is important, both in infants and 
older children. 

Another very important sign, which should always be looked for, is dis- 
placement of the heart towards the healthy side by the pressure of the effu- 
sion. There is large effusions on the left side ; we have found the heart 
pulsating below the right nipple. The value of this sign is particularly 
great in children, as it can be determined with accuracy even if their agi- 
tation or timidity renders other means of physical exploration difiicult. 

Rational Symptoms; Course; Duration. — Acute pleurisy is com- 
paratively rarely met with, as already stated, in children under six years 
of age, except as a secondary affection. In idiopathic cases it begins with 
severe pain in the side, cough, some difficulty of respiration, increased 
frequency of the pulse, loss of appetite, thirst, bilious vomiting, sometimes 
headache, and in rare instances delirium. The pain in the side or stitch is 
almost always present in acute cases, occurring in healthy children, while 
in those which are slight, or which occur in weak and debilitated subjects, 
or very young children, it very often cannot be detected. Sometimes, 
however, its existence may be ascertained in very young children by ten- 
derness of the side shown during the act of percussion. When present in 



RATIONAL SYMPTOMS. 231 

young children, it can always bo dotected by watrhinp; tlie face of the child 
and observing its gestures during the act of coughing, and during full 
inspirations, as in those made in crying, after sudden movement, or in the 
act of gaping. In an infant of thirteen months old, who was attacked 
with pleurisy of the right side, causing ctiusion of thick yellow pus into 
the right pleural sac, and which ended fatally within a month, only the 
blindest observer could fail to see that every act of coughing was acutely 
painful, for the child uttered each time a short, sudden cry, which was 
hushed as soon as given, while at the same moment there passed across the 
face an expression, amounting almost to a grimace, of suffering, which 
was unmistakable. The pain is aggravated by coughing, by full inspira- 
tions, by change of position, and by percussion. The seat of pain is almost 
always in front, but it may extend irregularly over the whole of one side 
to the arm, or it may be confined to the false ribs, or less frequently to the 
neighborhood of the nipple; it generally lasts from three to six days, though 
it sometimes continues longer. This symptom was complained of in most 
of the cases that we have seen. In some it was very acute and severe for 
one or two days, while in others it was slight, not well defined, and very 
transitory. In one, the child said there was no pain, but a sensation of 
weakness in the side when she coughed. In another, the pain was severe 
for a few hours, but was relieved by a sinapism, and was not felt again, 
though the attack resulted in a very large effusion into the side. In a 
third if lasted a week, and in a fourth only two days, though in both the 
effusion was extensive, and required several weeks for its absorption. In 
a fifth case it continued for five days. In the last, the effusion wjis very 
slight. It was aggravated in all these cases by coughing, by the act of 
respiration, especially when this was deep, and by motion. 

Cough exists in nearly all idiopathic cases, and generally from the onset, 
though sometimes not before the second or third day. Usually frequent 
and dry, it commonly retains these characters in acute cases, for four or 
six days, and then diminishes rapidly. In more tedious cases it continues 
for a longer time, but moderates in violence after some days. In secon- 
dary cases it has no special characters. It was present in all but one of 
the cases seen by ourselves. Its character varied very much. In somi; it 
was frequent, teasing, and very painful. In others it was rare, scarcely 
troublesome, and only slightly painful. In all it was very dry, this con- 
stituting one of its most marked features, and givmg it a very different 
character from the cough of bronchitis, and also, though somewhat leJ5S 
distinctively, from that of pneumonia. It continued almost entirely dry 
throughout the disease, except in a case which became complicated after a 
time with .slight bronchial inflammation, and, in that, it became loose. 
There is generally no expedorfition ; if any, it consists of a small amount of 
whitish, frothy, seromueous fluid. 

The rejfjiirfdifm is usually accelerated in acute rases, but remains natural 
in other respects; the dyspnoea, however, is slight, as a general rule, com- 
pared with that of pneumonia^ The difficulty of breathing is comrnrjuly 
ID proportion to the earliness of the age, and to the extent and rapidity 
with which the efiusion takes place. In the acute cases that came under 



232 PLEURISY. 

our own observation, the breathing was usually about 36, 38, 40, and 48, 
but in one case it rose to 68 for a single day. It was not labored, and ap- 
peared to be difficult only from the fact of its being more or less painful. 
In a case of double pleurisy that came under our observation, it was most 
laborious, and dreadfully painful, as was also the cough. In the cases at- 
tended with but slight pain, there was no dyspnoea. It usually subsided 
after two or three days, when large effusion took place, converting the case 
into the chronic form. 

The fever is not usually very great, and seldom lasts more than a few 
days, or a week. In some few cases, however, that we have seen, the 
febrile reaction has been very high. In one, in a child between three and 
four years old, the pulse rose to 172 on the first day, though the respira- 
tion was but 36 ; the skin was very hot and dry, and there was very great 
drowsiness and inattention. In other cases the pulse was 140, 128, and 
124. The acceleration of the pulse usually lasts three or four days, after 
which it falls, so that by the end of a week it is seldom over 70, 80, or 90. 
The heat of skin is not very great in most instances, and generally subsides 
rapidly and disappears after a few days. Thus during the first few days 
of the attack, the temperature may rise to 103° or 104° ; but it soon falls, 
and, during the remainder of the case, usually fluctuates between 100.5" 
and 102^. When the case is complicated with pneumonia, the elevation 
of temperature is even more marked and persists for a longer time. In 
acute secondary attacks, the febrile symptoms are more marked, a3 a gen- 
eral rule, than as has just been described, because of the existence of the 
concurrent disease. 

The countenance presents no particular characters, except that an ex- 
pression of pain passes across it occasionally when the child coughs, or 
takes a deep breath. It is seldom deeply flushed as in pneumonia. The 
alse nasi are dilated only during the continuance of the difficulty of res- 
piration. 

The decubitus is generally dorsal or indiflTerent. In two cases observed 
by us, in which the effusion was large, the number of inspirations was 
always from three to five greater when the child laid on the sound, than 
when on the affected side. 

Headache is often present during the first few days, in children over six 
years of age, and is sometimes very severe. 

Convulsions are said to occur sometimes at the onset in very young chil- 
dren. The strength is not usually much diminished, except during the 
acute period. The appetite is diminished and the thirst acute, but neither 
of these symptoms is so marked as in pneumonia. The tongue is usually 
moist, and sometimes covered with a coat of whitish fur ; the abdomen is 
natural. 

Bilious vomiting is said to occur in more than half the cases. The stools 
are generally regular, or there is some constipation. 

The Character. — The cough, pain, fever, and difficulty of breathing con- 
tinue for several days, after which all but the cough generally disappear, 
while that commonly persists in a mild form. In acute cases, the appetite 
now begins to return, the thirst moderates, and auscultation reveals only 



CHRONIC PLEURISY. 233 

feebleness of the respiratory nuirimir, with slight dulness on percussion. 
The general symptoms cease soon after this, and the patient is entirely 
convalescent in from one to three weeks, thtjuah feeble respiration and 
diminished resonance sometimes persist for a longer period. 

Urine. — The urine in pleurisy has the so-called febrile characters, but 
usually not in any degree approaching to the urine in pneuir.onia, the 
water being less diminished, and the urea less increased. In cases where 
there is rapid effusion into tlie pleura, the chlorides are lessened or almost 
wanting; and reappear as the effusion is absorbed. Albumen is scarcely 
ever present. 

Chronic Pleurisy may follow the acute form, or occur as an idio- 
pathic disease. In the former case, the acute symptoms diminish after 
a variable length of time, but the fever does not cease entirely, and often 
recurs towards evening and assumes a hectic type. In the latter case there 
is usually a very moderate degree of fever at first, which soon subsides and 
then disappears, or there is none at all ; the pain is generally, though not 
always, vague, uncertain, and attracts but little notice. In one case that 
we attended, the cough was frequent, rather dry, and very painful for the 
first few days, al\er which it became looser and ceased entirely, though 
the inferior two-thirds of the right side were filled with effusion for a 
periixl of two weeks afterwards. In a second, in which the whole of the 
left side was occupied by the eflTusion, there was no cough whatever. In 
a third, there was a very slight, infrequent cough during the first day, but 
after that, though the efl'usion occupied the right side up to the spine of 
the scapula, there was none through the day, and merely a little hacking 
at night. In a fourth, in a girl between four and five years old, there was 
considerable fever during the first week, but literally no local symptoms 
whatever, so that the case was mistaken for one of bilious fever by another 
physician. When it came under our notice, some obscurity in the symp- 
toms led us to examine the chest, where we found an effusion occupying 
the lower third of the right side. The fever was now diminishing, and 
soon disappeared, but the efliision increjised, without pain, and with only 
an occasional cough, until it filled up three-fourths of the side. It then 
stopped, and after several days began to recede. At the end of about six 
weeks the child was quite well again, and continues so to this time, about 
three years. In a fifth case, in a boy, between five and six years old, the 
attack was extremely obscure. There was very slight fever, almost no cough, 
indeed none except upon some exertion being made, and then scarcely 
I, ,'• "if^ and no severe pain. In fart, the child complained of no pain 
NM. 1 i, but upon being asked, referred to an uneasy sensation in the 
inferior lateral region of one side. The tongue was coated, and the symp- 
toms were rather those of some bilious derangement, than of anything 
more serious. It was not until after four or five days of attendance, that 
a careful examination of the chest showed the existence of a slight f'ff*usion 
in the right side. This gradually increased until it reached n« arlv iiii to 
the clavicle, and then slowly disappeared again. 

The above are mentioned as illustrations, cho-cn from tli*- very (on- 
siderable Dumber of cases we have met with, of the great irregularities in 



234 CHRONIC PLEURISY. 

the mode of development and general symptoms of chronic pleurisy, and 
of the danger of errors of diagnosis in consequence. 

The respiration is somewhat accelerated in all cases, and when the effu- 
sion is very large, and especially when it is purulent and attended with 
violent hectic fever, it is sometimes excessively labored and difficult. In 
some of the cases that we have seen, however, even when the effusion has 
been very large, the breathing has not been difficult. In one case it was 
between 40 and 50 during the first two days, after which it fell, as the 
effusion took place, to 30. In a second it was 45 at first; at the end of a 
week it was 38; at the end of the third week, as the effusion was being 
absorbed, it had fallen to 28, soon after which the recovery was com- 
pleted. In a third it was so. slightly disturbed that we did not at first 
suspect any disease of the chest. On the fourteenth day, the effusion 
reaching then nearly to the spine of the scapula, the breathing varied 
between 40 and 28 during sleep, but during the waking state there was no 
visible oppression. » 

The effusion is usually large, excepting in the very rare cases where it 
is circumscribed by adhesions. The side is evidently enlarged, the in- 
crease of size being visible to the eye, and readily ascertainable by men- 
suration. In addition, the tissues of the affected side seem tense, and the 
intercostal depressions are obliterated. The heart is pushed by the effu- 
sion towards the healthy side, so that the apex beat is considerably dis- 
placed ; and, if the right side be affected, the liver is pushed downwards 
so that its border can be detected by percussion one-half inch or more 
below the margin of the ribs. On careful inspection it will be seen that, 
while the respiratory movements of the healthy side are free and even 
much exaggerated, the side of the thorax on which the effusion exists is 
almost motionless during respiration. Percussion yields marked dulness 
over the seat of the effusion. If the pleural sac is not entirely full up to 
the clavicle, it will be found that, on changing the position of the patient's 
body, the upper line of percussion-dulness varies its position on account of 
the gravitation of the liquid. Quite frequently, if the effusion be large, a 
slight sense of fluctuation may be obtained by palpation of the intercostal 
spaces. 

Upon auscultation, the respiratory murmur is often suppressed. At 
other times, a distant and transmitted bronchial breathing may be heard 
over the seat of the effusion. This can, however, be distinguished from 
the clear, sniffling, superficial bronchial breathing of lobar pneumonia. 

In those cases of chronic pleurisy in children, the effusion is very apt 
to be purulent, constituting empyema or pyothorax. There are then, in 
addition to the symptoms and signs of pleural effusion, the evidences of 
marked hectic fever. The child emaciates, grows pale, and has fever in 
the latter part of the day, followed by night-sweats. In some cases where 
the effusion has been at first serous, and later becomes purulent, the de- 
velopment of empyema is clearly indicated by a return of elevated tem- 
perature, which now persists with very marked morning remissions and 
evening exacerbations. 

The course and modes of termination of chronic pleurisy differ much 



DIAGNOSIS. 235 

in different cases, chiefly in accordance with the character of the fluid. In 
a large proportion of cases where the effusion is serous, ahsorption gradually 
takes place under the influence of treatment in from one to five months, 
and the patient recovers with a contraction of the side, which eventually 
disappears as the compressed lung expands. "Where, on the contniry, the 
eftusion is purulent, ahsorption is impossihle, and unless paracentesis of 
the chest is performed and the pus drawn off', it will be spontaneously 
evacuated by ulceration through some point of the chest-wall or by an 
opening into the hing, or the child must die, worn out by the interference 
with breathing and by the persistent hectic fever. "When an external 
opening forms, it is most frequently in front and in the third or fourth 
intercostal space. We have, however, met with cases where the opening 
occurred low down in front or on the postero-lateral aspect of the chest- 
"When an opening forms into the lung, the occurrence is usually announced 
by a sudden and copious expectoration of pus. The following abstract 
fn^m our record of the case may be given, as showing the course of em- 
pyema when a spontaneous cure takes place by the evacuation of the fluid 
through an opening in the walls of the chest. This case occurred in a 
very hearty boy, of between four and five years of age. He was taken 
sick in the country, with what was supposed to be an attack of typhoid 
fever. After many weeks of violent illness, an abscess showed itself in 
the neighborhood of the left nipple. This, at the end of two months, dis- 
charged, and the patient began to improve. At the end of three months, 
he was brought to town, and we saw him. "We found a fistulous orifice, 
discharging occasionally considerable quantities of pus, just below and in- 
side of the left nipple. The left side was very much contracted, and the 
lung was retracted into the upper part of the chest. He was put upon 
cod-liver oil, wine, and nutritious food, and gradually improved. He was 
Boon removed to the country, and we did not see him again, but have since 
heard that he had entirely regained his health. 

Diagnosis. — Pleurisy may be confounded with pneumonia or hydro- 
thorax. From the latter afl^ection it is to be distinguished by the absence 
of pain in that disease, by the existence of the efl^usion on both sides of 
the thorax in many cases, and by the fact that hydrothorax generally fol- 
lows as a consequence of some previous disease, })articularly the eruptive 
fevers or nephritis. 

The distinction between acute pleurisy and lobar pneumonia is more 
diflicult than that between pleurisy and hydrothorax, and in some in- 
stances is subject to considerable doubt. It may generally l)e arrived at, 
however, by attention to the diflTerences lai<l down in the following table, 
which is taken from the Biblioth^que du Medecin Fradicien : 

ACrXE IDIOPATHIC PLEURISY. ACUTE IDIOPATHIC PNEUMONIA. 

Frpquf-nt after six years of age ; rare Froqnont aflfir mx years of njje ; more 
under that age. rare undf-r that age, but nuich 1cm »o 

than plc'urify. 

Begins with dry cough, sharp thoracic Begins with cough, slight thoracic 
pain, bronchial and metallic re<*piration pain, and crepitant or subcrepilant rhon- 
during inspiration, either on the first day chu*; at a later period there is brondiial 



236 PLEURISY. 

ACUTE IDIOPATHIC PLEURISY. ACUTE IDIOPATHIC PNEUMONIA. 

or later, and more rarely with obscurity respiration during the expiration and 
of the respiratory sound. bronchophony. 

Modification of the physical signs by No modification under like circum- 
chaniije of position. stances. 

Fever and acceleration of the respira- Fever violent ; considerable accelera- 
tion usually moderate. Rapid dirainu- tion of the respiration. Diminution of 
tion of these symptoms from the fourth these symptoms less marked, less rapid, 
to the seventh day. and not before the sixth or ninth day. 

Expectoration absent or very slight. Expectoration mucous; sometimes san- 

guineous; very rarely rust-colored. 

No rhonchi. Rhonchi preceding, following:, and 

often accompanying the bronchial res- 
piration. 

Absence of vibration of the thoracic Augmentation of vocal resonance very 
parietes during speaking or crying. sensible in older children, and in a less 

degree in all. 

Course of the disease irregular ; rapid Course of the disease regular ; steadily 
disappearance in some cases, prolonged increasing in most cases, and then di- 
duration in others. The bronchial respi- minishing from the sixth or ninth day. 
ration is substituted or masked by feeble Bronchial respiration more disseminated, 
respiration. 

In some cases, especially in young children, where the onset of pleurisy 
is very sudden and acute, the general febrile disturbance may entirely 
mask the local symptoms, and lead to the belief that some one of the ex- 
anthemata is about to develop itself. 

Thus we have met with cases where, in the midst of full health, the 
child has been seized with violent fever ; extreme restlessness alternating 
with stupor ; repeated vomiting ; great frequency of pulse ; acceleration 
of respiration ; but with little or no cough and no complaint of pain in 
the side. In one instance of this kind, the heat of skin, rapidity of pulse, 
and frequency of the vomiting were so marked that for twenty-four hours 
we suspected the approach of scarlet fever, and not until the second day 
were we able to satisfy ourselves of the nature of the attack by observing 
that the act of respiration was evidently painful, and by detecting the 
physical signs of plastic pleurisy over the right apex posteriorly. 

In two cases, one at the age of 3 months, the other at 1^ years, we have 
observed most excessive and almost tetaniform reflex irritability, so that 
the slightest movement of the child's body, or the attempt to examine the 
chest, would provoke violent startings and spasmodic contractions of the 
entire body. In both of these cases a fatal result followed, and post-mor- 
tem examination revealed the presence of localized empyema. 

The chronic form of pleurisy with extensive effusion may be easily dis- 
tinguished by the history of the case, by the physical signs which we have 
carefully detailed, and by attention to the character of the general symp- 
toms. 

Prognosis. — Acute pleurisy is rarely a fatal disease in healthy subjects. 
When it occurs as a complication of some other malady, on the contrary, 
it is much more apt to terminate unfavorably. The degree of fatality in 
secondary cases will depend, of course, in great measure, on that of the 



II 
II 



TREATMENT. 237 

primary disease. Pleuro-pneumonia is a more dangerous disorder than 
either alone. Of 5 cases of primary pleuro-pneumonia, observed hv Kil- 
liet and Barthez, 2 died; while of 10 secondary cases, 8 died. 

Of the 28 case^ of pleurisy that we have seen, 5 died. The 5 fatal cases 
were all primary; 4 of them occurred in infants, 2 at 6 weeks, and the 
others at 13 and 18 months respectively, and the fifth was a case of double 
pleurisy in a boy between 4 and 5 years old. Of the 23 children that re- 
covered, one was between 1 and 2 years of age ; one between 2 and 3 ; 
three between 3 and 4 ; while eight were between 4 and 5 years of age, 
and the remainder over that age. In our experience, therefore, the mor- 
tality was, as might have been expected, much greater in those cases occur- 
ring at a very early age. 

Chronic pleurisy is generally a serious, and sometimes a fatal disease, 
though since the more frequent and more skilful use of paracentesis many 
cases are cured which would formerly have proved fatal. 

Treatment. — The hygienic treatment in this, as indeed in all the diseases 
of children, is of the utmost importance, and ought to be regulated by the 
practitioner himself. In all forms of the disease, the child should be care- 
fully protected from cold, and in the acute form, kept at rest, and, if possi- 
ble, in bed. The diet must be very strict, and should consist for a few days 
of the preparations of milk. After the fever has disappeared, bread and 
milk, vegetable soup with a few oysters boiled in it to make it agreeable, 
and gradually rice, potatoes, and at last small quantities of meat, may be 
allowed. In the chronic form the diet ought to be nutritious, but regulated 
with equal care as to quantity and material. In that form the patient 
should be taken into the air if the weather be mild and dry, and in winter 
the chamber ought to be well aired from time to time. 

Bloodletting. — In acute cases occurring in vigorous children over five 
years of age, marked by intense fever and pain in the side, and which 
are seen soon after the onset, local depletion may be employed. The 
amount of blood to be taken should not exceed two or three ounces; 
and this should be withdrawn by small cups applied over the seat of 
inflammation. In younger children, as well as in all whose constitutions 
are not robust, it is better to limit ourselves to the use of a few dry cups. 

Depletion in any form ought to be avoided in most of the secondary cases, 
unless the symptoms are very acute and the child strong and vigorous ; also 
in all chronic cases, after the febrile symptoms have been dissipated, and 
in feeble, delicate children. 

AntimoniaU — Fehrifngen — Opiates. — A moderate use of the antininnials 
is of great service in the acute stage of the disease. »SmaIl doses of anti- 
monial wine and sweet spirit of nitre, or fractional doses of sulphuratetl 
antimony, as recommended in the article on pneumonia, will generally 
cause the fever, dyspnoea, and cough to subside rapidly. Large doses are 
unnecessary in any case, and are liable to be injurious in all. 

In cases in which annraonials ought not to be used, as where they are 
opposed by some idiosyncraay, in children of low vital force, and in the 
secondary form of the disease, we have found a citrate of potash mixture, 
containing ipecacuanha and opium, and digitalis, when the heart is much 



238 PLEURISY. 

excited, very useful. The quantity of opium must be proportioned to the 
pain. When this is severe, the doses must be full. The good effects of 
this remedy in serous inflammations are now generally acknowledged. 
At two years of age, one drop of laudanum in the above mixture, every 
two hours ; or half a grain of Dover's powder, with the twelfth of a grain 
of sulphurated antimony, every two hours, until a decidedly tranquillizing 
effect is obtained, may be used. When positive drowsiness has been brought 
about, the doses ought to be given at longer intervals — every three or four 
hours. 

Mercury. — In former years mercury was constantly employed in con- 
junction with bloodletting. In our last edition we opposed its use as un- 
necessary in acute cases, but stated that there was high authority for 
employing it in cases of the acute form tending towards the chronic, and 
in confirmed chronic cases ; adding, however, that we had not found it 
necessary even in these. We find, now, that Dr. West, of London, still 
speaks highly of it. He says (loe. cit, p. 303) : " After depletion, our 
chief reliance is to be placed on calomel, which should be freely given in 
combination with opium or Dover's powder; and an attack of pleurisy 
thus treated will often be cut off in thirty-six or forty-eight hours." Dr. 
J. Lewis Smith, of New York {loe. cit, p. 279), does not even mention 
mercury in his remarks on treatment. Dr. Thomas Hillier {Diseases of 
Children, Amer. ed., 1869, p. 87) says : " Formerly I gave mercury to all 
cases of primary pleurisy, but this practice I have discontinued, except in 
the form of an aperient. Instead of it, salines, such as acetate of am- 
monia, nitrate of potash or soda, the citrate of potash, and nitrous ether, 
are given." 

The experience we have had, since we last wrote, has not at all in- 
creased our faith in this remedy. We believe that as time goes on, and 
knowledge grows, there is good reason to think that the good effects 
formerly ascribed to calomel in such a variety of diseases, were largely 
due to the medicines given with it, and particularly the opium (without 
which it was not often used), the ipecacuanha, the salines, and even the 
antimonials. 

The remedies employed by ourselves, after the disappearance of the 
acute symptoms, when the effusion has taken place, and especially if 
there seems any tendency for the case to pass into the chronic form, are 
either iodide of potassium in syrup of sarsaparilla, according to the fol- 
lowing formula : 

K. — Potass. lodidi, gr. xvj ad xxxij. 

Syrup. Sarsap. Comp,, 

Aquae, aa, fjj. — M. 

Dose, a teaspoonful three times a day ; 

or the syrup of the iodide of iron, of which from thirty to sixty (^rops 
should be substituted for the iodide of potassium in such a mixture as the 
above. The iodide of potassium is preferable in the early stage, and may 
have the acetate of potassa associated with it. After a time, and especially 
in ansemical and delicate patients, the iodide of iron should be substituted. 



TREATMENT. 239 

Under this treatment, combined with tlie application of a Burgundy pitch 
plaster to the side, or some other form of counter-irritant, the etiusion lias 
usually disappeared in from two to eight weeks, though diuretics may have 
failed to make any impression on the cases. 

Diuretics are highly recommended in the treatment of cases in which 
effusion has taken place. Those chiefly employed are squills, digitalis, 
and nitre. The squill is given alone, or in combination with digitalis, and 
by some with calomel, or with both. The dose of the powder of squill or 
digitalis, is about a quarter of a grain every two or three hours. The 
squill may be used also in the form of syrup or oxymel, and the digitalis 
in tincture. These two substances may be employed in the following 
formula : 

R.— Acet. Scill.T, f3ij. 

Tinct. Digitalis, gtt. xxx. 

Aquae Fluvial, fjiv. — M. 

Of this a teaspoonful is to be given three or four times a day to children 
two years old. 

Parf/atives ought to be used during the acute stage of pleurisy to an ex- 
tent sufficient to keep the bowels soluble, and to act as mild evacuants. 
In chronic cases, on the contrary, they are particularly recommended as 
evacuants, in order to deplete the bloodvessels, and thus hasten the ab- 
sorption of the effusion. So far as our experience goes, this treatment is 
unnecessary, as diuretics and alterative tonics are generally sufficient, 
without a resort to violent remedies, which must irritate the intestinal 
raucous membrane, always extremely susceptible in children, to a danger- 
ous degree. 

Tonics are often necessary in chronic, and sometimes, after the febrile 
symptoms have subsided, in acute cases occurring in feeble and delicate 
children. The most suitable are quinine, in the dose of a grain morning 
and evening, small quantities of port wine, and the preparations of iron. 

External Remedies. — Blisters are very generally employed, in the acute 
form, to relieve pain and dyspnoea, and, in the chronic, to hasten the al)- 
sorption of the effused liquid. We did not api)ly them in the cases under 
our charge, having succeeded very well without; but would not hesitate to 
make use of a small one, applied for a not longer period than two hours, 
if the pain and oppression persisted. In chronic pleurisy the application 
of a large Burgundy pitch plaster, made rather weaker than wliat is used 
for adults, and large enough to cover nearly the whole side, would ix- |)n'f- 
erable to blisters. We are also in the habit of painting the chest-wall, 
over the seat of the effusion, with dilute tincture of iodine, every day, or 
as frec|uently as the irritability of the skin will permit. The fallowing 
mixture is of about the proper strcnjrth for a young child : 

B— Tr. lodinii, f-^iij. 

Chloroform, f^j. 

Alcoholis, f^iv— M. 

ParaceniesU. — Of late years, the operation of paracentesis, in cases of 



240 PLEURISY. 

pleurisy, both acute and chronic, has been performed so frequently, and 
with such encouraging results, that it may now be considered to occupy 
an assured position among the remedies for certain conditions of this dis- 
ease. It appears desirable, therefore, to discuss somewhat in detail the 
circumstances in which it is applicable, the indications which call for it, 
and to a certain extent the mode of its performance. In doing this, we 
shall avail ourselves freely of the admirable and exhaustive discussion of 
this operation by the lamented Trousseau (Clinique Medicale, torn, i, pp. 
619-698), to whose practice and teaching it was in great part due that 
paracentesis thoracis was first generally recognized as a justifiable opera- 
tion for the relief of excessive pleuritic effusions. 

In acute pleurisy he recommended the operation more frequently than 
most authorities consider necessary. Whenever, indeed, the effusion be- 
comes so excessive as to almost entirely fill the pleural sac on the affected 
side, displacing the adjacent viscera seriously, whether the patient presents 
intense dyspnoea or not, he advises its performance. The reasons urged by 
him for this practice were, that although ordinary cases of acute pleurisy 
almost invariably recover, yet when such excessive efflision exists, it may 
prove fatal in more than one way. It has not very rarely happened that, 
from the obstruction to respiration, conjoined with the embarrassment of 
the heart's action due to its twisting and dislocation, death has occurred 
suddenly ; and we have met with the records of several cases in children 
which had this unfortunate and unexpected termination. 

Again, in these cases of excessive serous effusion, if the fluid be not re- 
moved either by absorption or paracentesis, there is great danger that the 
case will be converted into one of empyema, not from the actual conver- 
sion of the serum into pus, but from the altered condition of the secretion 
from the pleural surface. 

But even when the fluid does not become thus converted into pus, but 
remains clear and serous, absorption is very slow, and the patient may 
perish from exhaustion and hectic fever. During the long time necessarily 
occupied in the absorption of the fluid also, the pleurisy really becomes 
less and less curable, since the lung contracts such close and dense ad- 
hesions as prevent it from ever fully expanding again. Finally, if any 
tuberculous diathesis exists, the long course of the pleuritic attack favors 
very greatly the development of phthisis. 

The chief objections which have been urged against the performance of 
paracentesis in these acute cases are that the effusion will form again 
rapidly, requiring repeated punctures and exhausting the patient; that 
the operation prolongs the duration of the case; and. that there is danger 
of converting the serous efiTusion into a purulent one. 

In regard to the first of these, however, experience has shown that in 
many cases a single puncture is suflS.cient, and that even when the fluid 
does reaccumulate, it is rarely to such an extent as to demand a repetition 
of the operation. 

There is, again, no reason for supposing that the puncture, if properly 
performed, can in any way tend to prolong the case. In regard to the 
last objection, the cases recorded sufficiently show that if care be taken to 



TREATMENT — PARACENTESIS. 241 

prevent the admission of air, there is not nuich reason to apprehend the 
convei-siou of a serous into a purulent collection, unless the constitutional 
condition is so impaired that in all probability the case would have passed 
into one of extensive empyema, had the operation not been performed at 
all. Indeed, it is proved by the direct experiments of Nvsten and Ilew- 
son, that air injected into the pleural cavity does not the least harm to the 
<erous membrane. 

Since the recent introduction of the greatly improved apparatus for 
performing paracentesis, also, this source of danger is to a great extent 
removed. By means of Bowditch's instrument, or better still, by one of 
Dieulafoy's aspiratoi-^, the etlusion can be withdrawn through a canula so 
fine that its puncture scarcely creates the slightest irritation, and at the 
same time with entire exclusion of air. In this manner, paracentesis has 
been performed repeatedly of late years, even in the acute stage of pleu- 
risy, without being followed by any of the unfavorable restdts formerly 
so much dreiided. 

In view of the various risks incurred in cases of excessive hydrothorax, 
Trousseau thus sums up his remarks upon the operation : " Whenever 
auscultation and percussion reveal the presence of a very large eflusion, 
whether its formation has been attended with acute symptoms or not, which 
interferes seriously with respiration, even though dyspnoea is not marked ; 
and when this eftusion tends to increase, despite the active employment of 
local and general remedies for nine or ten days, the operation is indicated." 
He especially directs attention to the fact that the mere amount of dysp- 
noea must not be taken as a guide, since this may be absent, although 
there are at the same time evidences of grave interference with the oxida- 
tion of the blood. If, however, during the existence of such an effusion, 
spells of suffocative dyspnoea should ensue, or syncopal attacks, the opera- 
tion is urgently called for. 

In the London Hospital Reports for 1865, these views are warmly ad- 
vocated and powerfully supported by Dr. Fraser, who believes that the 
operation should be more generally employed than at present. 

We have already alluded to the fact that occasionally an extensive 
effusion will remain serous for a long time, hut in the majority of cases, 
and especially in children, it sooner or later becomes transformed into pus. 
Indeed, so frequently does this occur, that West expresses his conviction 
that in every case of idiopathic pleurisy in childhood, in which fluid is 
poured out in considerable quantity, the effusion is either originally puru- 
lent or becomes so verv speedily. In these unfortunate cases, where there 
is little or no disposition to absorption, where marked hectic fever and ex- 
hausting night-sweats soon set in and rapidly debilitate the patient, and 
wh« re the mwt favorable result that can be hoped for is that the pus will 
either evacuate itself externally, or open into the lung and be exiK-cto- 
rated, the operation of paracentesis should be undoubtedly performed. 

It is evident, indeed, that paracentesis must here have many advantages, 
since in ca.ses where the pus discharges externally spontaneously, it is 
almost invariablv about the fourth interrwtal ppace, and outside of the 
nipple, at a point therefore which renders it impowible for the pUH to freely 

16 



242 PLEURISY. 

evacuate itself, and which thus tends to keep open the fistula for a very- 
long time. Again, it not rarely happens in these cases that the fistula 
does not lead directly into the pleural cavity, but that the pus has bur- 
rowed in the thoracic walls, leading to denudation and necrosis of the ribs 
or sternum. 

The termination by the establishment of a pulmonary fistula, and the 
evacuation of the pus through the bronchial tubes, is a comparatively 
favorable one, but yet the case is apt to be more tedious, and certainly the 
lung-tissue must be much more seriously aflfected than when a free exit is 
given to the matter by the operation of paracentesis. In these cases, of 
course, the effusion will almost certainly form again, and either require 
repeated punctures, or a fistula will be established, through which pus 
will discharge almost daily. 

In addition to the advantages afforded by relieving the system of this 
source of irritation, and giving the lung a chance to expand, paracentesis 
enables us also to introduce medicated fluids into the thorax, and thus to 
modify the diseased pleural surface. We will detail below the injections 
which appear to us most useful for this purpose. 

Although, even under the most favorable circumstances, empyema is a 
most dangerous and not rarely fatal affection, numbers of cases are on 
record in which life has been undoubtedly saved by a recourse to this 
operation, and it has been noticed that the proportion of success is much 
greater in cases of children than of adults. Thus, out of 46 cases in child- 
hood, 13 of which occurred in West's practice, no less than 35 terminated 
favorably, there being one death in every 4 cases. 

In a recent paper by M. Guinier, of Montpellier {Bull, de VAcad. de Med., 
t. XXX, p. 645 ; Bien. Retrospect of New Syd. Soc., 1865-6, p. 152), the par- 
ticulars of 31 cases from different authors are recorded. The patients 
were of all ages up to 14 years ; as many as 16, however, were in their 7th, 
8th, or 9th year. In one of his own cases, a rapid recovery was effected 
in a case of extensive sero-purulent pleural effusion in a nursing child one 
year old. The mortality was about 1 in 6 ; and in no instance does the 
operation appear to have done any harm, but, on the other hand, seems to 
have relieved suffering and retarded death even in the fatal cases. 

One reason of this greater success in early life possibly is, that the much 
greater mobility of the chest-walls in children allows a rapid contraction 
of the thorax to occur after the pus has been withdrawn, so that the chest- 
wall comes in contact with the lung, which, in such cases, is always bound 
down by dense and strong adhesions ; whereas, in adults, the more un- 
yielding character of the thorax maintains a space between the two layers 
of pleura for a much longer time. On the other hand, it must be evident 
that this same greater mobility of the chest-walls will enable an excessive 
pleural effusion to be tolerated more readily, and with less injurious effect 
upon the thoracic organs, than can occur in the comparatively rigid adult 
chest. 

The great deformity of the thorax which ensues upon empyema in child- 
hood is rarely permanent, but as the lung slowly expands, the thoracic 
walls gradually regain their normal shape, the depression of the shoulder 



TREATMENT — PARACENTESIS. 243 

disappears, and in the course of a few years at the farthest, scarcely any 
trace of distortion or contraction remains. 

Our own opinion in regard to the propriety of this operation, and the 
indications for its performance, is as follows: Id ordinary cases of pleurisy 
in children, with moderate eftusion, it is unnecessary. Whei' the effusion 
is very extensive, and causes marked displacement of the heart, distension 
of the aftected side, and severe disturbance of breathing, the question of 
operating should always be raised, and if, after consultation with the 
parents', it is determined upon in case of necessity, all pre})arations for its 
performance should be made, and we should hold ourselves in readiness to 
perform it immediately on the appearance of urgent symptoms. Still so 
long as there is no reason to dread that the case is passing into the stage 
of empyema, we should recommend a faithful trial for several weeks of 
the internal remedies, especially digitalis and iodide of potassium, and of 
the local use of repeated applications of dilute tincture of iodine. In 
many cases where the effusion has been thus extensive and of quite long 
standing, we have thus obtained speedy and complete cures, without de- 
formity of the thorax. If, however, positive reduction in the amount of 
efiusion did not soon begin to show itself, we would unhesitatingly operate. 
Finally, in all cases where the symptoms lead us to conclude that the efiu- 
sion is more or less purulent, the duty of immediate operation is an im- 
perative one. 

In regard to the performance of the operation itself, it may be said to 
present no difficulty whatever. All the sources of difficulty, and particu- 
larly the entrance of air, have been obviated by the improved means of 
operating lately introduced. 

The procedure originally recommended by Trousseau is as follows: The 
patient being placed near the edge of the bed in a semi-recumbent posture, 
his body steadied by an assistant, a small incision is made through the 
skin in the sixth or seventh intercostal space, a little outride the line of 
the external border of the pectoralis major. An ordinary trocar, the canula 
of which is protected by a valve of goldbeater's skin, thin gutta-percha, or 
a piece of animal membrane of any kind, is then placed in this wound and 
thrust boldly into the pleural cavity, the precaution l>eing taken of gra,«p- 
ing the instrument so that not more than one inch shall be free, to avoid 
all possibility of wounding the lung. 

It is preferable, we think, if a simple trocar and canula be used, that a 
piece of narrow india-rubber tubing should be attached to the end of the 
canula, and that the trocar should be passed through from the outside of 
the tube close to the canula, so that after the puncture into the chest has 
been made, the trocar may be withdrawn, when the little hole in the elastic 
tube will close and prevent any entrance of air. The free end of the india- 
rubber tubing should be carrie<l under the surface of some water placed io 
a vessel intended to receive the effusion as it escape**. Thus we can simply 
but surely effect the withdrawal of the fluid without permitting the entrance 
of air. 

These methods of operating have been almost entirely . d fince 

the iDventioD of Bowditch's syringe, and better »till, of J ' v •* aspi- 



244 PLEURISY. 

rator. The latter instrument consists of a syringe, to be attached to the 
canula after its introduction through the chest-wall and the withdrawal of 
the trocar, and so constructed that by turning a valve, a vacuum is created 
in the barrel when the piston is drawn out. The valve being again turned, 
the fluid is sucked from the chest into the barrel of the syringe until this 
latter is filled. A still further turn of the valve establishes a communica- 
tion with a lateral outlet ; the piston is pushed home and the syringe 
emptied. The vacuum is then renewed, and so the operation is continued 
until the effusion has been withdrawn so far as desirable. Another im- 
provement in the details of this operation, which has a great influence upon 
the degree of irritation caused by it, is the use of a very small canula for 
making the puncture. 

It is necessary that the thrust given to the trocar should be fearless and 
quick, since if it be pushed in a hesitating way, the point may push before 
it the layers of false membrane which probably coat the pleura, and the 
effusion will not be reached. Should this accident occur, an attempt may 
be made to break through the false membrane by a probe introduced 
through the canula, or a second puncture must be made in a different 
place. 

Different opinions exist in regard to the advisability of withdrawing the 
entire effusion at once, but experience has, we believe, shown that no un- 
fortunate results need be apprehended from so doing. The last portions of 
fluid which escape are apt to be stained with blood, probably from rupture 
of the delicate new-formed vessels of the false adhesions. 

The dressing of the wound should be as simple as possible, consisting 
merely of closing the incision by a piece of adhesive plaster, over which a 
pledget of lint may be secured by a bandage round the thorax. 

Almost the only unpleasant symptom which follows the removal of the 
fluid is spasmodic cough, which often comes on in severe, and at tiipes pain- 
ful paroxysms. Syncope is scarcely ever noticed, if the patient be kept in 
a state of absolute rest after the operation. The internal remedies, espe- 
cially the diuretics, should be continued, and Trousseau recommends, what 
we have also found useful, that the side should be painted with tincture of 
iodine. 

When we have reason to believe that the effusion is purulent, which as 
we have already remarked, is very frequently the case in childhood, there 
are some points of difference in the operation. Thus we can have no hope 
that the effusion will not form again, and either require a second operation, 
or, as frequently happens,, cause the cicatrix of the first puncture to re-open. 
Again, before the case is brought to a successful termination, it is often 
necessary to employ some medicated injections to alter the character and 
secretion of the pleural surfaces. 

It is doubtful, therefore, whether the admission of a small quantity of 
air is very objectionable, although AY est believes that it almost always con- 
verts the previous healthy pus into a highly offensive sero-purulent dis- 
charge. The ill effects of this can be overcome by the injections to be 
recommended below; but, on the other hand, care must be taken not to 
admit so much air as would interfere with the expansion of the lung. It 



TREATMENT — PARACENTESIS. 245 

is adviable on the whole, however, to perforin the first puncture with the 
same care, and to enipkiv the same dressing as in the case of serous effu- 
sion. But if a second puncture is required, or if the first one re-opens, the 
wound should be enlarged so as to admit a good-sized canula, which should 
be allowed to remain. This canula should be of silver, curved so that its 
extremity may not come in contact with the gradually expanding lung; and 
its shield should l>e furnished with a ring of caoutchouc, placed between 
the instrument and the skin, to prevent excoriation. 

After the pus has been withdrawn, the pleural cavity may be washed 
out thn>ugh the canula with tepid water, and then there may be injected 
about an ounce of a mixture of 1 part of tincture of iodine to from 4 to 7 
parts of tepid water, eflfected by the aid of a little iodide of potassium. 

The canula should then be closed by a cork, and not disturbed for 
twenty-four hours, when the accumulated ])us should be witlulrawn, and a 
second injection practiced. In the first injections it is better probably to 
allow the iodine solution to run out again ; but after we have assured our- 
selves of its effect, it may be allowed to remain. Throughout the contin- 
uance of the treatment the pus should be allowed to escape at least once 
every day, though as the secretion diminishes the iodine injections may be 
practiced only at longer intervals, as once in two, three, or four days. The 
effects of these injections are usually very beneficial ; they correct the fetor 
of the discharge, diminish its amount, and never, so far as we are aware, 
are productive of pain or increased inflammation. In cases where they 
appear to have lost their good effects, other agents may be substituted, as 
weak solutions of carbolic acid, chlorinated soda, or aromatic wine. 

In cases which terminate favorably, the discharge diminishes gradually, 
though often very slowly, the chest contracts, and finally there is nothing 
left but a fistula, which for a short time discharges a few drops of serous 
pus before healing. As an example of the tolerance to this treatment 
shown even by young children, and of the good results finally obtained iu 
many desperate cases, we would refer the reader to the extraordinary case 
recorded at length in Trousseau's Clinique MCdicaie (t. i, pp. 650-.j2), 
where, in a boy of 6 years, the canula was allowed to remain for eleven 
months, during which time medicated injections were constantly emjiloyed. 
The amount of pus discharged in all is estimated by Trousseau as not less 
than 80 pounds, and yet perfect recovery finally ensued, and at the date 
of the report the child's health was excellent. 

Another method of operating in cases of empyema, which, following 
the example of Dr. H. Lenox Hodge of this city, we have performed with 
entire success, consi.st« in passing a large curved needle with a stout handle, 
armed with fine rubber drainage-tube, into the chest through the soft tis- 
sues io an intercostal space, and bringing it out through the next interspace 
above. The needle is then unthreaded and withdrawn ; the drainage- 
tube remains; the spf)t is covered with a fK)ultice or a wad of oakum ; dis- 
charge occurs freely through the tube ; and it is easy to conduct any subse- 
quent treatment, such as al>ove recommende<]. 

The following case is abstracted from the hospital record, as illustrating 
the excellent results of this mode of treatment : 



246 



PLEURISY. 



Empyema of right side of 8 months duration : paracentesis : introduction of a drairi- 
age-tube, followed by entire recovery. 

E. A., a healthy boy of 12 years of age, was attacked in February, 1875, with severe 
pleurisy on right side. The acute symptoms subsided in 7 weeks, but left him weak 
and short of breath. On admission to the Hospital of the University of Pennsyl- 
vania, the physical signs indicated an effusion on right side reaching up to clavicle, 
and it was evident from general symptoms that it was purulent in character. On 
October 13th, 1875, the day of admission, he was tapped by Dr. Pepper in the seventh 
interspace on line of anterior border of right axilla, and f^xxx pus were withdrawn. 
A considerable amount still remained, and on October 22d, the effusion having re- 
formed, a fine rubber drainage-tube was introduced around the seventh rib by means 
of a large curved needle. A wad of oakum was applied over this and secured in 
position by a bandage. The amount of discharge was at first very large, but steadily 
diminished. The chest contracted, the lung expanded partially, the heart returned 
to its normal position, and in February, 1876, he was discharged cured, the dis- 
charge having ceased and the opening closed after the withdrawal of the drainage- 
tube. The general treatment consisted of cod-liver oil, quinia, syrup of the iodide 
of iron, nutritious diet. 

In October, 1876, one year after this operation he was carefully examined. The 
chest was found to have returned to its healthy symmetrical state, and all traces of 
the previous disease had disappeared. 

During the course of such cases, every attention must be paid to sustain- 
ing the child's nutrition by abundant nourishing food, stimulus, if needful, 
bitter tonics, iron, and cod-liver oil. 

We subjoin the following case to illustrate thie remarks we have made 
upon the treatment of pleurisy, and to show the importance of faithfully 
employing suitable internal remedies before resorting to paracentesis, in. 
cases where the effusion is serous and not so excessive as to seriously em- 
barrass respiration. 



Case of chronic pleurisy of the. left side., beginning iinlh acute symptoms ; extensive 
effusion^ with displacement of the heart to the right of the sternum: recovery. — The 
subject of the case was a boy four years old, of delicate stature and appearance, but 
enjoying good health. We saw him first at 1 p.m on February 12th. He was per- 
fectly well the day previous, slept soundly during the night, and rose apparently 
in good health in the morning. He ate his usual breakfast but complained after- 
wards of feeling unwell. Soon after this he complained of headache, of soreness 
and weakness in the knees in going up stairs, and then of violent pain in the left 
side beneath the armpit. 

At the time of our visit, he was in bed, in the following condition : pulse 130, full 
and strong; skin warm and moist; headache ; sharp, severe pain at the prsecordia, 
extending backwards under the armpit, and aggravated by motion, crying, and by 
deep inspirations ; respiration quick and jerking. No cough at all ; absolutely none. 
Abdomen natural ; neither vomiting nor diarrhoea. Tongue slightly furred and 
moist. Action of heart violent ; impulse strong and felt over a large space ; sounds 
loud and strong ; to the left, and beneath the nipple, a soft murmur with the second 
sound. Percussion dull over a larger space than natural. 

Behind, percussion dull over whole of left side ; natural on right side. Kespira- 
tion natural on the right side ; feeble and indistinct, without bronchial sound, on 
the left. 

Ordered a teaspoonful, each, of extract of senna and syrup of rhubarb, to be given 



TREATMENT — PARACENTESIS. 247 

immediately; to have a warm batli in the evenins:, and to tiike one of the following 
powders every two or three hours, beginning in the evening: 

R.— Pulv. Opii et Ipecac, gr. iij. 

Potass. Nitmt., gf- vj. 

M., et div. in chart, no. vi. 

February 13. Passed a restle^^ night. Better to-day. Pulse 130; softer; skin 
moist. Impulse of heart less violent. Pain not so severe. Respiration still quick, 
and when the child is excited or irritated, it becomes jerking, while at other times 
it is quiet. Physical signs as before, except that the murmur, with the second 
sound of the heart, is no longer heard. Ordered three ounces of blood to be drawn 
bjT leeches from the left side; powders to be continued so as to allay restlessness and 
pain. 

February 14. Has had a better night. Pulse less frequent. Respiration 30, and 
without jerking; no cough at all; makes no complaints of pain. The appetite is 
returning. 

February 15. Better in all respects; no fever nor pain; no cough. Physical 
signs a* before. 

The case went on until the 27lh of March, when we paid our last visit, making 
the whole duration of the case over six weeks. During the last two weeks of Feb- 
ruary, there were no acute symptoms. The fever had disappeared entirely. The 
r--i i'ltion c»»ntinued, however, from 28 to 30 during all that time. The effusion 
tKvuji.d n*»arly the whole of the left sid»^, which was manifestly larger than the 
right, and the intercostal spaces were protruded. Behind, there was total flatness 
on percu.«sion. from the spine of the scapula downwards, and in front from a short 
distance beneath the clavicle. The respiratory murmur was absent in the lower 
three fourths of the dorsal region, and feeble above. In front, respiration was 
heard only above and just beneath the clavicle. In the course of this period the 
heart was gradually forced over to the right side of the sternum, so that at lust its 
impulse was felt, not to the lefi, but to the right of that bone. The cardiac sounds 
were loudest and most distinct in the same rcijion. The displacement was so re- 
markable that the mother discovered it herself, as we had avoided telling ht^r to 
save her from anxiety. The new position of the heart did not seem to produce any 
inconvenience in addition to that occasioned by the pleuritic effusion. During the 
last two we«'ks of March the child was k^pt in bed ; his diet was milk and bread ; a 
large Burgundy pitch plaster was kept on the side, and he took internally, vine- 
gar of squill and tincture of digitalis. 

Finding th«t the effu.-ion remair.fKl stationary under this treatment, we prpscrihed 
a grain of iodide of potassium three times a day, in a tea.spoonful of conipound 
syrup of sarsnparilla. The diet was changed at the same time. He was allowed 
small quantities of meat every day, and was taken from bed and placed in a chair 
by the window. Under this treatment h*» gradually improved, so that by the 27lh 
of March, when we paid our last visit, the effusion had in great moa^ure «lisap- 
peared, and he was able to play atmut the room all day. The side was slightly 
contracted; the respiration was pure and vesicular, but rather more feeble than 
on the left side ; the h«>art bad returned to its natural position. 

We examined this child six years later, and found him to be in excellent health. 
Excepting a slight contraction of the left side, there was no perceptible difference 
between that side and the right. 



248 PNEUMOTHORAX, 



AKTICLE VI. 



PNEUMOTHORAX. 



In this condition there is an accumulation of air in one or both pleural 
cavities. The source of this air is either from without, when there is an 
opening through the chest-wall ; or from the bronchial tubes, when there 
is perforation of the pulmonary pleura. There are a certain number of 
cases recorded, in which it is supposed by the authors that a secretion of 
gas has occurred from the pleural surface, or that it has been directly de- 
veloped from the decomposition of some inflammatory effusion in the pleu- 
ral cavity ; but the evidence upon which the possibility of such occurrences 
rests is insufficient, and for clinical purposes, at least, it may be assumed 
that where pneumothorax exists, there has invariably been some communi- 
cation established between the pleural cavity and the atmospheric air. It 
is, therefore, to be regarded not so much as a distinct disease, as a compli- 
cation of many other pathological conditions. There are peculiarities, both 
as to the cause and symptoms of this condition as it occurs in childhood, 
which render a separate account of it desirable. It is, however, certainly 
comparatively infrequent in children, owing in part to the rarity of the in- 
juries and wounds, which often cause traumatic pneumothorax in adults ; 
and in part to the fact that the diseases, especially empyema and tubercu- 
losis with the formation of vomicae, which are the most frequent causes of 
it in adults, are either less frequently attended with this complication in 
children, or are of comparatively rare occurrence. 

Anatomical Appearances. — Pneumothorax may be found to exist on 
both sides, but as a mere pathological condition which, of course, must have 
produced death immediately. It is nearly always limited to one pleural 
sac, and before the thorax is opened, the affected side is observed to be dis- 
tended, with prominent intercostal spaces. The percussion-phenomena, 
which will be hereafter described, persist, and it is sometimes possible by 
rapidly moving the body, while the ear is placed in contact with the chest, 
to develop a succussion-splash. If a small opening be made through an 
intercostal space, the compressed air will often be heard escaping with a 
hissing sound, and occasionally the current has so much force as to extin- 
guish a lighted candle held near the opening. The air which escapes is 
usually, but not always, of offensive odor, in consequence of being tainted 
by the decomposition of the pleuritic effusion which is apt to coexist. If 
the entrance of air has followed a penetrating wound of the chest, or a 
compound fracture of the ribs, the familiar appearance of these lesions 
will be found. More frequently it has depended upon perforation of the 
pulmonary pleura, in consequence of some morbid action, and we may then 
detect the spot of perforation, and study its characters, by filling the chest 
with water and blowing through a tube into the trachea, when a stream of 
air-bubbles will be seen to rise through the fluid from the point of aperture, ? 

I 



ANATOMICAL LESIONS. 249 

unless this has been obstructed by hiyers of false membrane. The lung 
itself will be found more or less extensively collapsed, according to the 
nature of the lesion which has caused the perforation. It can rarely be 
inflated completely in consequence of the free escape of air through the 
pleural opening. The adjacent movable viscera are displaced by the pres- 
sure of the gaseous collection, even to a greater extent than in many cases 
of hydrothorax. The position of the perforation in the pleura varies, but 
is most frctjuently found at some part of the middle lobes, or the a'djacent 
parts of the upper and lower lobes. We have, however, found two points 
of rupture in one case, both seated near the apex. The opening itself 
is usually rounded, or occasionally lenticular; in size it varies from one 
to three lines in diameter. The edges of the pleura are thin, and often 
softened and discolored. There may be but a single point of perforation, 
or several may coexist, either grouped closely together over an abscess of 
considerable size, or scattered over the surfiice of the lung (as in the case 
on the following page\ each opening corresponding to a distinct abscess. 

The condition of the lung varies exceedingly, and, of course, presents 
the appearances proper to the lesion which has caused the pneumothorax. 
Thus there will be found in about the following order of frequency, the 
appearances, elsewhere described in their appropriate places, of tubercu- 
losis of the lungs (either in the form of softening subpleural miliary for- 
mations, or of small superficial vomica?) ; of small superficial abscesses 
resulting from lobular pneumonia ; of circumscribed apoplexy or gan- 
grene of the lung; or of vesicular and interlobular empliysema with 
subpleural bulhe. In most cases, there are evidences of pleurisy asso- 
ciated, and the pleural cavity contains a variable quantity of tluid, either 
turbid or bloody serum, or ichorous pus ; and, at the same time, the sur- 
faces of the pleura may present patches or organized layers of lymph. 
Of course, these appearances will be most marked in cases where the per- 
foration of the pleura has resulted in consequence of a previous empyema. 
In other cases, the fluids found in the pleural sac have in part escaped 
from the lung-tissue through the perforation, and are in part due to the 
pleuritic inflammation suj^rinduced. The irritation caused by the mere 
admission of air into a healthy pleural sac is not always suflicient to ex- 
cite inflammation, and thus in rare cases, where pneumothorax results 
from the rupture of an emphysematous bulla, the pleura may present no 
inflammatory exudation whatever. But in the great majority of cases, 
either from the fact that pleurisy coexists, or that there is an escape of 
pus from the lung at the time of perforation, the pleura presents the ap- 
pearances above described. It occassional ly happens that, owing to the 
previous existence of pleuritic adhesions over a part of the lung, the es- 
caping air is circumscribed, and produces only a local pneumothorax. In 
such cases, of course, all the alterations of the thorax, as well as the atten- 
dant physical signs, are limited to the seat of the gaseous collection, and 
may, indeed, be associated with the evidences of chronic pleurisy, with re- 
traction of the remaining parts of the chest. In still other cases, although 
the pleura has been perforated, the escape of air is entirely prevented by 
the existence of adhesions of the pleura over the point of rupture ; or, tm 



250 PNEUMOTHORAX. 

in the interesting case reported on page 221, by the close apposition of en- 
larged bronchial glands. 

The following case, which, owing to the absence of any clinical history, 
possesses chiefly an anatomical interest, may be given, as showing the usual 
conditions of a pneumothorax dependent upon pneumonia : 

Case. — Partial Suppurative Pneumonia: Superficial Abscesses, with Suhpleural 
Emphy!?ema: Perforation of the Pleura: Pnewnothorax : Miliary Tuberculosis. — 
Mary McC, aged 13 months, died February 11th, 1868, after a short illness, dur- 
ing which the most marked symptoms were dyspnoea and cough, with occasional 
vomiting. At the autopsy, there were all the physical signs present of pneumo- 
thorax of the left side. The right lung was found congested and partially collapsed, 
but admitted of complete inflation. In the posterior part of the fissure between 
the upper and middle lobes, the upper lobe presented a separation of the pleura 
from the lung to the extent of half an inch in diameter. On the apposed portion 
of the lower lobe there was a similar large bulla. The lung-tissue immediately 
subjacent to these cavities was consolidated to a distance of an eighth of an inch. 
On cutting into the bullae, they were found to be distended with air and dark sa- 
nious pus, and their cavities presented minute trabeculae and septa, consisting of 
bronchioles and the remains of ruptured air-vesicles. There evidently was no gan- 
grene of the lung-tissue, so that it appeared that these lesions had resulted from a 
combination of patches of suppurative pneumonia of the superficial laj^er of the 
lung with suhpleural emphysema ; and it seemed reasonable to conclude from the 
unusual relations of the emphysematous bullae, that they were due to the process of 
softening, which had opened a connection between some of the terminal bronchioles 
and the suhpleural connective tissue. There were scattered miliary tubercles in the 
upper lobe. 

The left lung presented two similar but larger bullae (fully one inch in diameter), 
in exactly the corresponding position between the upper and lower lobes. There 
was a small perforation of the pleura in the one in the upper lobe. Two other 
similar but smaller cavities were found on the surface of the lower lobe, in each of 
which the separated pleura presented a perforation about one-sixth of an inch in 
diameter. There were traces of localized pleurisy in the neighborhood, but no ad- 
hesions ; and a considerable pneumothorax had resulted, causing collapse of at least 
one-half of the lung. 

The bronchial glands, spleen, and kidneys contained miliary tubercles. There 
was no decomposition of the tissues. 

Causes. — Although, as already stated, pneumothorax is a compara- 
tively rare disease in children, it will be found, when present, to occur 
most frequently in young children (under the age of 5 years), and espe- 
cially in those of feeble constitution. The causes which directly lead to 
its development vary greatly in their relative frequency, as compared with 
the causes of pneumothorax in the adult. 

Thus we find that the most fruitful cause of pneumothorax in children 
is unquestionably tuberculosis of the lungs. In adults this condition leads 
to perforation of the pleura usually only after the production of a vomica; 
but in children, excavation of the lung-tissue to any extent is rare in 
tuberculosis, and when it does occur is quite constantly associated with 
such close adhesions of the neighboring pleural surfaces, as would effec- 
tually prevent the escape of any air into the pleural cavity, even in 
event of a perforation of the walls of the cavity. It is found, therefore, 
that pneumothorax more frequently results from the softening of small 



SYMPTOMS. 251 

superficial tubercles, which iuvolve the pleura and load to its softening 
and perforation. 

The next most fruitful cause of pneumothorax in children is probably 
pneumonia, when it passes on to the staire of suppuration with the forma- 
tion of a superficial abscess, which seems most likely to happen when the 
iufiammation occurs in a localized and circumscribed form. The three 
cases with which we have ourselves met were all due to this cause. It is 
probable that this unfortunate termination is much more frequent is sec- 
ondary pneumonias (especially those following such diseases as measles, 
or, as in one of our cases, severe remittent fever), and, in a number of the 
eases, miliary tubercles have been found associated, as in the instance 
quoted above by us. In such cases the plastic exudation formed on the 
pleural surface is often too small to prevent the escape of air after the 
perforation has occurred. 

Gangrene of the lung and the softening of superficial patches of pul- 
monary apoplexy, are mentioned by several authors, particularly by Ril- 
liet and Barthez, as following next in order of frequency. But, according 
to our own observation, empyema, with consequent ulceration of the pleura 
and communication witli the bronchi, although not so frequent a cause of 
pneumothorax in children as in adults, yet furnishes more cases than either 
of the former rare conditions. Occasionally, also, when the purulent fluid 
in empyema has discharged itself externally by an ulcerated opening in 
an intercostal space, air has found entrance to the pleural cavity, and pro- 
duced a pyopneumothorax. 

Finally, pneumothorax has been known to follow the rupture of a sub- 
pleural bulla in cases of interlobular emphysema. It is especially in such 
cases that the collection of air may be found without any coexisting liquid 
efl^ision. It is probable, however, that were life to be prolonged after such 
an occurrence, some pleural inflammation would be established, and lead 
to serous efl^usion. 

In most cases the actual perforation of the pleura is the result of the 
progress of the pulmonary disease which has ultimately involved the 
serous membrane in its course ; but it is probable that the rupture may be 
at times precipitated by any violent eflfort, particularly by a fit of cough- 
ing or severe vomiting. 

Symptoms. — In some cases where the antecedent disease is a very grave 
one, and the strength of the child is greatly reduced, the supervention of 
pneumothorax is with difficulty detected, and death occurs from the sud- 
den increa.se of obstruction to the respiration before an opportunity is 
aflforded for careful examination. 

The occurrence of the perforation is often marked by an abrupt and 
decided increase of the dyspncea which has already existed in consccjucnce 
of the preceding disea,se. It will, however, be readily understood that 
this increase in oppression is not of such constant occurrence in children 
as in adults, owing to the fact than in the former all acute disetistis of the 
chest are apt to be attended with an extreme degree of dyspntca. So, too, 
the sharp lancinating pain iwually complained of by adults at the time 
of the development of pneumothorax may be latent, or only revealed by 



252 PNEUMOTHORAX. 

increased agitation, and more hurried, shallow breathing. In some of 
their cases, Rilliet and Barthez observed a cough which they considered 
peculiar, and described as "short, frequent, jerking, painful or convulsive, 
and sharp or piercing;" and a similar cough has been noticed by other 
observers. 

In cases where death does not occur very quickly, and where a careful 
examination of the chest can be secured, the physical signs of pneumo- 
thorax are much more characteristic than the general symptoms. The 
affected side is distended, and its intercostal spaces bulge slightly. The 
respiratory movements are overactive on the opposite side to atone for the 
marked impairment of motion of the affected one. Percussion over the 
seat of the pneumothorax gives either merely exaggerated resonance, or a 
tympanitic or amphoric sound. Frequently this morbid resonance will be 
found associated with dulness upon percussion in some parts of the thorax, 
owing to the coexistence of consolidation of the lung or of pleuritic effu- 
sion. It may also happen that if the distension of the affected side be 
extreme, the tympanitic resonance will grow more or less flat, owing to the 
overtension of the thoracic walls. According to the condition of the lung 
and the character of the opening in the pleura, the respiratory murmur 
may be absent, or be present as metallic bronchial breathing, or more 
frequently as pure amphoric breathing. The vocal fremitus has generally 
been found decidedly diminished. Metallic tinkling has been detected in 
several instances; it was observed by Barrier to be most distinct during 
the effort at coughing. We are not aware that a splashing sound, such as 
can so frequently be developed in cases of pneumothorax in the adult, by 
succussion, has yet been observed in children. 

The adjacent movable viscera are found to be displaced by the pressure 
of the gaseous accumulation, especially in left-sided pneumothorax, where 
the dislocation of the heart to the right is very marked. Of course, if the 
pneumothorax be circumscribed, the above physical signs will be limited 
to the same spot. 

It will thus be seen that the symptoms of this condition in children 
closely resemble those which it presents in the adult ; but that in many 
cases it is impossible, owing to the great agitation of the child, to fully 
demonstrate their existence. 

Course; Prognosis. — The course of pneumothorax in children is 
usually a rapid one. Occurring, as it does, as a complication of some 
serious pre-existing disease of the lung, it so increases the respiratory em- 
barrassment as to generally induce death in from a few hours to a few days. 
In rare instances only is life prolonged for a few weeks. The prognosis, 
although regarded by Rilliet and Barthez as, on the whole, less unfavor- 
able than in the same condition in adults, is still exceedingly grave, both 
from the serious character of the condition itself, and from the grave 
nature of the diseases (tuberculosis, secondary pneumonia, gangrene of 
the lung, interlobular emphysema) in whose course it occurs as a compli- 
cation. Rilliet and Barthez observed one case where recovery ensued 
after the positive signs of pneumothorax had persisted for twenty days in 



COURSE — PROGNOSIS. 253 

a boy 3 years of age. They regarded the case as origiually one of pneu- 
monia. 

We have also observed a case, in a boy 11 yeai-s old, during an attack 
of secondary pneumonia, complicating a severe bilious remittent fever, 
where complete recovery ensued, though after a most violent illness; and 
it would indeed seem that, with the exception of the comparatively rare 
traumatic cases, the prognosis of pneumothorax in children is most fa- 
vorable when it occui-s in this connection. 

SteHen {Kiinik d. Kindei'krankheiten, bd. i, p. 137, et al.) expresses this 
opinion also, and places as the next most favorable variety that which 
is associated with empyema. Although it might be expected that pneu- 
mothorax resulting from the rupture of emphysematous buUiv would be 
of favorable prognosis, on account of the trifling amount of pleural in- 
flaniFuation which often attends that lesion, the fact is that this condition 
of the lungs themselves is so serious that a fatal result has followed in all 
cases so far recorded. 

In regard to the diagnosis, it is quite true that the occurrence of pneu- 
mothorax in the course of one of the thoracic diseases which we have seen 
it may complicate is apt to be overlooked, either owing to the want of 
symptoms definite enough to arouse suspicion of the development of some 
new lesion, or to the difficulty of securing a careful physical examination 
of the chest. When, however, this physical exploration is made with the 
frequency and care which are demanded in every case of acute thoracic 
disease, especially when threatening symptoms exist, the characteristic 
physical signs will be determined, and can scarcely be attributed to any 
other than the true cause. 

Treatment. — The management of pneumothorax must be considered 
always with reference to the primary disease which it complicates, and 
its occurrence must not be allowed to interfere with the prosecution of the 
treatment necessary for this. As it is evident, however, that this addi- 
tional le.*ion will still further tax the vital powers, and as the only chance 
of recovery lies in maintaining life till the cause, if curable, is removed 
and the air absorbed, we would advise that all remedies capable of re- 
ducing the strength or disturbing nutrition should be discarded, and that 
by every means the system should be sustained. In addition, we >hould 
recommend the moderate use of sedatives — either in the form of the prep- 
arations of opium or hyoscyamus, associated with bromide of ammonium 
if the cough be very severe and paroxysmal, to quiet agitation and ex- 
cessive dyspncea, and to relieve the cough. Great relief will also be ob- 
tained by .strapping the afliected side with strips of adhesive pla.ster, 
overlapping each other, and reaching from the spine to the stenuim, so 
as to restrict the mobility of that side to a great extent, and also to exert 
a considerable pressure up*^)n it. 

If the distension of the affected side and the pressure on the surround- 
ing organs be great, and the evidences of im|>eded circulation and oxida- 
tion of the blomi are threatening, recourse may be had to puncture thrriugh 
an intercostal space with a very fine trf>car. Although the results of thi« 
operation must be regarded as palliative rather than curative in moet 



254 HOOPING-COUGH. 

cases, yet as the paracentesis itself is attended with no danger, its perform- 
ance is to be recommended whenever the signs of pressure from the accu- 
mulation of air in the pleural sac become alarming. It is especially in 
cases where there is a liquid effusion associated with the gas (constituting 
a hydro- or pyopneumothorax) that paracentesis will afford most relief. 
In one case of this kind, Hennig performed paracentesis, evacuating a 
large amount of purulent liquid and gas, with very great relief to the 
symptoms of oppression. The child, a boy of 4 years of age, lived four 
weeks after the operation, and then sank from exhaustion. 



ARTICLE VII. 

HOOPING-COUGH, OR PERTUSSIS. 

Definition; Synonyms; Frequency. — Hooping-cough is character- 
ized by a hard, convulsive cough, occurring during expiration, and 
accompanied by long, shrill, and laborious inspirations, which are called 
hoops. The cough occurs in paroxysms, which are terminated by the 
expectoration of tough phlegm, and often by vomiting. 

The disease is known by various other names, of which the most com- 
mon are tussis ferina, chincough, and kincough. The frequency of the 
disease is exceedingly variable, as it occurs both in the sporadic form and 
as a widely-prevailing epidemic. Some idea of its frequency may be 
gained from the facts that, during the five years from 1844 to 1848 inclu- 
sive, there were 390 deaths from it in Philadelphia, under 15 years of age, 
out of a total mortality of 31,162. During the five years from 1864 to 
1868 inclusive, there were, out of a total mortality of 76,354, 543 deaths 
from hooping-cough ; a proportion considerable smaller than that during 
the first period of five years above mentioned. The irregularity is even 
more strikingly seen by comparing single years with each other: thus, 
while in 1867, there were but 65 deaths from this cause, there were no less 
than 208 in 1862. 

Causes ; Age. — It occurs generally in children, and may be met with 
in the first weeks of life; indeed, Watson in his lectures, mentions a case 
where the mother, during the last week of her pregnancy, lived in a house 
where the disease was prevalent, and her infant hooped the very day it 
was born. Of 208 cases in children, in our own private practice, 26 
occurred in the first year of life, 147 between the ages of 1 and 7 years, 
and 35 between 7 and 12 years. To be more explicit, we will state that 
of 188 cases in which the age was accurately noted, 11 occurred in the 
first six months of life ; 9 between 6 and 12 months ; 30 in the second 
year; 17 in the third, 32 in the fourth, 17 in the fifth, 30 in the sixth, 16 
in the seventh, 13 in the eighth, 8 in the ninth, 3 in the tenth, and 1 in 
the eleventh and twelfth years of life each. Of 130 cases in children, col- 



SYMPTOMS. 2o5 

lected by M. Blache, 106 occurred between 1 and 7 years of ago, and only 
24 between 8 and 14. Of 29 cases observed by MM. Killiot and Bartliez, 
there were 26 between 1 and 7 years, and 3 between 8 and 12. It is 
stated by MM. Blache, Rilliet and Barthez, and Valleix, to be most com- 
mon in girls. Of 208 cases observed by oui-selves, 10(> occurred in boys, 
aud 102 in girls. Some writers have asserted that certain co)i.'<titntio)i)< ixnd 
hereditanj inffuence predisjxise to the disease. So far as our own experience 
goes, it has seemed to attack indifferently those who were simultaneously 
ex|>osed to it. The fact of its being propagated by direct contaffion is 
proved beyond doubt by numerous observations. We have rarely known 
CDC child in a family to be attacked without its extending to all the othera 
Dot protected by having had the disease previously. That it often appears 
also in the form of an epidemic, is established by the testimony of many 
writers, so that at present no doubt is entertained upon this point. 

Symi*toms. — It is customary to describe three stages of hooping-cough. 
The first is called the stage of invasion, or the catarrhal stage ; the second 
the stage of increase, or the spasmodic stage; and the third the stage of 
decline, which is characterized by an amendment of all the symptoms. 

Fir.*t Stage. — The great majority of the cases begin with the ordinary 
symptoms of simple catarrh. These are coryza, sneezing, slight injection 
of the conjunctivie, and dry cough. The cough rarely has any peculiarity 
in the beginning which will enable us to distinguish it from that of an 
ordinary cold, though some persons have asserted that they could recog- 
nize it. We have often listened with great care to the sound of coughs 
which parents supposed might be hooping-cough, but were always obliged 
to confess our inability to determine, until time gave them more decided 
characters. In addition to the symptoms enumerated, there is generally 
more languor, lassitude, drowsiness, and irritability, than are commonly 
present in simple catarrh. In a small proportion of cases the first stage is 
wanting, and the disease assumes its peculiar features from the first. The 
duration of this stage is very uncertain, and is ascertained with difhculty. 
Our own experience would fix it at about two weeks as the average, though 
it may last undoubtedly a much shorter or longer period. The earliest 
period at which we have known the distinctive hoop of the disease to be 
heard was in three days. In another ca.^ it was five days. We have also 
known it to appear at a later period than usual. In a good many instances 
it has l)een as late as three weeks, but very rarely later. 

Second Stage. — At the beginning of this stage the disease has a.s8umed 
its f)€culiar convulsive and paroxysnuil character. It consists of violent 
fits or paroxysms, or as they are often called, kinks of cough, recurring 
after longer or shorter intervals. Just before the paroxysm the child seems 
restless, anxious, and irritable, or else keeps perfectly quiet and evidently 
tries to retard its approach. When it begins, the child, if lying down, rises 
up suddenlv, or if playing about runs to take hold of some fixed object, by 
which to .support itself during the accession. The cough is dry, spasnunlic, 
and sonorous, and occurs in a succession of short, rapid expirati(»nM, by which 
the thorax seems to be emptie<l of all its air with violent efforts. It is 
followed by one or two long and deep inspirations, which are accompanied 



I h 



25G HOOPING-COUGH. 

by the peculiar hoop to which the disease owes its name, and which is 
caused by the drawing of the air rajjidly and forcibly through the nar- 
rowed glottis, which is spasmodically closed. During the fit the face be- 
comes deeply suffused or even purple, and swollen ; the eyes are watery, 
and the countenance is expressive of great anxiety, and after the fit is over, 
of fatigue and exhaustion. The latter symptoms are, as M. Valleix re- 
marks, the signs of partial asphyxia, and are the result doubtless of the 
complete expulsion of air from the thorax, and a consequent partial sus- 
pension of the function of hsematosis. There is almost always an expecto- 
ration of colorless ropy fluid, often accompanied by vomiting, at the close 
of the fit of coughing, and the patients usually appear weak and languid 
for a short time, after which they return to their play. 

In very severe cases there are other symptoms in addition to those just 
mentioned. Hcemorrhages from the mouth, ears, nose, lungs, and beneath 
the coujunctivse, are not unusual. We have ourselves seen several instances 
of epistaxis, one of effusion into the eyelid's, a few of extensive subcon- 
junctival ecchymosis, and we are well acquainted with the history of another 
case, in which there was bleeding both from the nose and ears. In one 
case, in a girl between five and six years old, that occurred to one of our- 
selves, in which the paroxysms were violent, the spells were accompanied 
in the latter half of the fourth and in the fifth week, by a discharge of a 
good deal of blood from the mouth. This took place particularly during 
the night-spells, so that in the morning the basin would contain several 
teaspoonfuls of blood. It was not from the nose. It was bright in color, 
pure, except that it was intermingled with sero-mucous expectoration, but 
it was not intimately blended with the sputa, nor was it streaked through 
the mucus as it sometimes is in the pneumonia of children. On one occa- 
sion it was seen to fly from the mouth in a little spirt, as though from a 
vessel. The child was lively and well all this time, playing about, eating 
well, strong, not thirsty, without pain, not oppressed between the spells, 
and sleeping naturally between the paroxysms at night. The only altered 
physical sign was slight dulness on percussion over the upper part of the 
right lung behind, with some subcrepitant rale at that point, but without 
bronchial respiration. After lasting twelve days, it ceased ; the child got 
well gradually, and continues strong and hearty to the present time. In 
another, case, in a girl two years of age, which came under our own obser- 
vation, a species of syncope, a state of insensibility without convulsive 
movements, accompanied by great paleness, occurred after many of the 
paroxysms. 

We have met with general convulsions in 12 cases, 5 of which proved 
fatal. In 2 other cases, both occurring in infants under six months, the 
paroxysms of cough were accompanied by the most violent struggling and 
oppression, and by deep blueness of the hands and feet, like that of severe 
cyanosis. 

In some instances, after the paroxysm is apparently over, the child will 
begin within a few instants to cough again, and may in this way have sev- 
eral fits in such rapid succession as to make an almost continuous paroxysm. 
It is quite common for this to happen twice, and in one case which we saw, 



SYMPTOMS. 257 

it occurred three times on several occasions. The ordinary duraiwii of a 
paroxysm or kink, is from a quarter to three-quartei-s of a minute, though 
it may hist as K)ug as two minutes, or according to some even longer. In 
a casie that occurred to ourselves, one paroxysm lasted the extraordinary 
period of tifty-five minutes. That it was really a paroxysm of the disease, 
we are quite sure, as it chanced that we reached the house shortly after it 
began, and witnessed the greater part of it oui-selves. The number of ac- 
cessions in twenty-four houi-s is very irregular. It depends chiefly on the 
stage and violence of the attack. During the height of the disease, we 
have generally found them to number about 40. In some rare cases, how- 
ever, they are much more numerous, and amount to 70 or 80. They are 
generally most frequent in the course of the third or fourth week, after 
which they remain stationary as to frequency for several days, or for two 
or three weeks, and then decline gradually. The paroxysms may occur 
spontaneously, the child being often disturbed from sleep by their sudden 
occurrence, or they may be excited by various circumstances, such for 
instance as contrarieties, a fit of crj'ing, change of position, eating, violent 
exercise, and imitation. We have frequently seen an attack brought on 
by the sight of another child in a paroxysm of the disease. The duration 
of the second stage may be stated to be about 30 or 40 days in most cases. 

Third Stage. — It is impossible to fix a precise limit from which to date 
the beginning of this stage. It is generally, however, said to commence 
frura the time when the disease is evidently on the decline. The paroxysms 
now grow less frequent and less violent, the cough reassumes some of the 
catarrhal features which it had at first, and gradually loses its peculiar 
spasmodic character. The child's general health improves, the appetite 
becomes vigorous, the strength is invigorated, the sleep again becomes 
sound and tranquil, and the disease disappears. The duration of this stage 
is uncertain, like that of the two othei-s. MM. Rilliet and Barthez state 
it to be short in uncomplicated cases (ten to fifteen days), and are of opin- 
ion that when it has been supposed to have lasted several weeks or months, 
it has been the result of some complication, as chronic dilatation of the 
bronchia, tubercular disease, etc. It ha})pens not unfrequently, however, 
that after the disea.se has apparently ceased, all the distinctive characters 
of the cough recur, if the child chance to take cold within a few weeks or 
even longer after its disappearance. 

In ca.*es of pertussis unaccompanied by complications of any kind, there 
are no marked general symptoms. There is seldom any fever, the appetite 
continues good, and with the exception of occasional languor and fatigue, 
and irritability of temper, the child appears to be well. 

Urine. — No accurate analyses of the urine in i>ertussi3 appear to have 
been made. Gibb and Johnson, however, state that they have found sugar 
in variable quantities in almost every case. This question 'appears well 
worthy of full investigation, since, if this statement is confirmed, it would 
link itfelf in the most interesting manner with the other evidences in this 
disease of irritation of the pneumogastric nerves, which are at least some- 
what concerned in the glycogenic function of the liver. 

The total duration of the disease, in simple cases, may be set down at from 

17 



258 HOOPING-COUGH. 

one to three mouths. We have never known a case to last so short a time 
as a mouth, and have rarely found the whole duration much within three 
months. 

Complications. — Though it has happened to us, on several occasions, to 
meet with children who have been very ill from the violence of the disease 
under consideration in its uncomplicated condition, we have never knowu a 
case to prove fatal except in consequence of some kind of complication. It 
is exceedingly important, therefore, that the various accidents apt to occur 
in the course of the disease should be carefully considered. 

Convulsions. — This complication is not a rare one, since it occurred in 5 
of 29 cases observed by MM. Rilliet and Barthez, and in 12 of 208 ob- 
served by ourselves. It is one of the most dangerous accidents liable to 
occur in the course of the disease. Of the 7 cases reported by the authors 
quoted (5 of their own, and 2 belonging to M. Papavoine), 6 died. Of 
our 12 cases, 5 died. In all that we have seen, the convulsions were gene- 
ral, extremely violent, and accompanied by insensibility in the fatal cases 
to the last, and in the favorable ones, during from a few minutes to half 
an hour. In two of the fatal cases the pertussis had lasted nearly two 
months, and was accompanied by extensive bronchitis. The fatal event 
took place within twenty-four hours from the supervention of the spasms. 
The subjects were eight and nine months of age respectively. In the third 
case, the convulsions came on in the seventh week of the disease, in a child 
who had been laboring for a number of days under bronchitis. They 
ended fatally in seven hours. In the fourth they occurred in a child in 
the second year of its age, at the end of about four weeks, proved fatal in 
two days, and were caused by bronchitis and collapse of the lung-tissue. 
In the fifth case they occurred likewise in a child in the second year of 
life, were attended with violent laryngismus and contraction, and proved 
fatal in the third week of the disease. 

One of the favorable cases occurred in a child five months old, who 
had been attacked with bronchitis three days before the occurrence of the 
convulsions, which came on during the height of a severe paroxysm of 
coughing. The convulsive movements were general, and continued for 
about half an hour, after which the child was drowsy or irritable for some 
hours longer. The hooping-cough continued to be severe for two weeks 
after this, as many as 42, 46, and 48 paroxysms occurring every day. At 
last, however, perfect recovery took place. The second favorable case was 
that of a girl between two and three years old, in whom a convulsion oc- 
curred in the third week of the disease, before the paroxysms had become 
violent, and evidently in consequence of an attack of fever dependent 
upon dentition. The seizure lasted only a few minutes, was followed by 
drowsiness for a few hours, but on the following day all the unpleasant 
symptoms ha!i disappeared. In a third case, in a boy between two and 
three years old, a violent convulsion occurred at the end of the second 
week, at the beginning of an attack of pneumonia. The child remained 
very ill, and nine days afterwards had another convulsion, which was 
much slighter than the first. After this he gradually recovered. In a 
fourth case, in a girl between two and three years old, a slight but well- 



COLLAPSE OF THE LUNG -TISSUE. 250 

marked convulsion occurred at the onset of an attack of bronchitis, wliich 
took place at the beginning of the third week of the hooping-cough. The 
bronchitis proved to be very severe, but there was no return of the spasm, 
and the child recovered. In a titth case, in a boy nine months old, a 
severe fit occurred in the sixth week, just at^er the child had been brought 
home from an expetlition to procure his daguerreotype. It lasted fifteen 
minute^:, and was attended with total insensibility, and pur()le discolor- 
ation of the face, but in half an hour after, the patient was nursing well, 
and was entirely conscious. There was no return of the convulsions, 
though the disease was very severe after this attack. In the sixth case, 
also in a boy nine months old, a slight convulsion occurred during one 
of the parox>*sms in the fifth week, but was not followed by any bad con- 
sequences. 

Amongst the complications ought to be ranked, we think, though this 
has not generally been done by writers, an excessive degree of the laryn- 
gismus which constitutes one of the natural and essential features of the 
disease. In some children, in fact, and especially in those of a nervous 
ten t. and in the anemical and debilitated, and, likewise, in cer- 

taii i<' types of the disease, this laryngismus assumes a degree of 

severity which is not only distressing but positively dangerous. In one 
case that occurred to ourselves, in a child who had suffered many months 
before from laryngismus and contracture, the occurrence of hooping-cough 
re; lie lar}*ngismus, and after a few weeks caused death almost 

in-- >ly, at the beginning of a paroxysm, as the child was sitting 

upon the floor, where it had been placed only a few moments before to 
play, it having presented before this no very threatening symptoms. In 
another case, in which we could detect no other complication, the spasm 
of the glottis was so very violent, that after a few days the spells were 
attended with convulsions, and very soon ended fatally. In a third, this 
symptom was so violent that in many of the spells the child ceased for 
the time to breathe, seemed to faint, became entirely unconscious, and 
had to be fanned and carried to an open window to be revived ; this pa- 
tient ultimately recovered. In a great many cases, this symptom, without 
<'{]:■ r tmplicatioD, has been most distressing, and has required particular 
*: ut. 

' ;/j«<? of the lAing-Tissne. — The recent discoveries in regard to the 
paii.w..»gic-al change in the pulmonarj' tissue called collapse, and especi- 
ally a consideration of the causes by which collapse is produced, might 
well had us to suppose that pertussis, and esp*>rially the bronchitis of [)er- 
tu»*i^, Would be very apt to become associated with collapse. Late re- 
searches accordingly show that of all the lesions met with in hor)ping- 
cough this is much the most frequent and important. Dr. Ciraily Hewitt, 
of I»ndon, in a lecture on the pathology of hooping-cough, read before the 
Ha-' ■::: ^ i- TV of I>mdon, in 1855, shows "that the catarrhal inflam- 
niari ji ^r tn- t.ronchial tubes, which occasions h<H)ping-cough, is, iti fatal 
case>, attended almost univen»ally with collapse of the lungs." He states 
that his observations were made upon nineteen subjects, whose age varied 
from four yean to one month, the average being eighteen months. " In 



260 ^^^^TWraWWuGH. ^^^^^^^H 

all, the state of the lungs was carefully noted. The chief lesion found 
after death was collapse of the lung-substance. The following is a state- 
ment of the degree to which this pathological condition manifested itself 
in the difterent lobes of the two lungs. 

" In the right lung, portions of the upper lobe were found collapsed in 
six cases, and in four more to a less degree. The middle lobe was col- 
lapsed, wholly or in part, in sixteen cases. The lower lobe w^as more or 
less affected with collapse, in eighteen cases. In the left lung, the upper 
lobe presented the same lesion in fifteen cases, the whole of the anterior 
tongue-like prolongation being in most of the cases affected. The lower 
lobe was collapsed more or less in eighteen cases. In seven of the cases, 
the portions collapsed were also congested, in some to a high degree. 

" The test of MM. Bailly and Legendre, viz., the inflatability of the por- 
tions of the lung thus affected, was used in almost all the cases ; and on 
that and other grounds, it was determined, that the particular part of the 
lung in question was collapsed and not hepatized. 

" It will be at once perceived, that the occurrence of collapse was almost 
universal ; all the cases, with the exception of one, in which there was ex- 
tensive tuberculization of the lungs, presenting a greater or less amount of 
lung-substance affected in this manner." 

We have had but few opportunities of testing this matter for ourselves 
by post-mortem examinations ; but in one case to which we were called in 
consultation, that of a boy not quite a year old, this lesion was shown, by 
autopsy, to be present to a great extent. The child had had the disease 
during three months with considerable severity. He was thought to be 
doing well, until he was taken one day a long drive into the country. 
After the ride he seemed very much fatigued, and that night was seized 
with very great dyspnoea, increased violence of the coughing spells, and 
after a short time with general convulsions. We saw him on the follow- 
ing day. He was breathing very rapidly and with much effort, there was 
a good deal of subcrepitant rale through the chest, the skin was cool, and 
about the mouth had a cyanotic tint, and he was unconscious. The same 
symptoms persisted through the day with occasional convulsive seizures, 
and on the following day he died. At the autopsy, there was found very 
extensive collapse of both lungs, as proved both by the anatomical ap- 
pearances, and by inflation. There was no pneumonia, and very moderate 
bronchitis. 

Bronchitis has always been supposed to be the most frequent complica- 
tion of hooping-cough, and there can be no doubt that it is one of the most 
important. The recent discoveries of the existence and nature of collapse 
have shown, however, that many of the fatal cases, hitherto ascribed to 
bronchitis, or to bronchitis and pneumonia combined, must have been 
cases of collapse, so that large allowances must be made for all statistics 
collected before the discovery of the true nature of the last-named lesion. 

There is, as has already been stated, a certain amount of pulmonary 
catarrh in every case of hooping-cough. This is a normal element of the 
disease. To constitute a complication there must be a true bronchitis, an 
inflammation of the bronchial mucous membrane, sufficient to produce the 



COMPLICATIONS. 261 

orHinarv symptoms of that disease. This exists in a great many cases; 
M>[. Killiot and Barthez found it to exist either alone or combined with 
pneumonia in half of the fatal cases. Of the 208 cases observed by our- 
selves, it existed to a greater or less extent in 42. In 28 of these it was 
mild or onlv motierately severe, and of these all but one recovered. In 14 
it was severe and very extensive, or else capillary, and of these 6 died. Of 
the fiital cases, it was in several no doubt attended with collapse of the lung- 
tissue. In fatal cases, it has often been found accompanied by continuous 
dilatation of the smaller bronchia. 

Pneumonia, according to the authors above quoted, is about as frequent 
as bronchitis. When, however, the ftital termination took place soon after 
the beginning of the disease (18th, 26th, or 27th days) it was not generally 
present. After these periods, on the contrary, it was almost always ob- 
served. As these authors, however, include under the title of lobular 
pneumonia, many cases of bronchitis with collapse, it is clear that a large 
number of their cases of supposed pneumonia ought to have been ranged 
under the head of bronchitis. For our own part, we have met with only 
five well-marked cases of pneumonia. Two of these occurred in girls of 
seven and nine years old respectively, one in a girl between one and two 
years of age, a fourth in a boy between two and three years old, and a fifth 
in a bov in his ninth year. Thev all recovered. The des^ree of dan^rer 
from this complication is in proportion to the earliness of the age at which 
the disease occur?, and to the extent of the inflammation. 

Emphysema undoubtedly follows or accompanies hooping-cough in some 
cases. In a considerable proportion of fatal cases the lesions of vesicular, 
and, less frequently, of interlobular emphysema are discovered. These 
will be found described in full in our article upon the latter affeetion, 
where we have also alluded to the rare occurrence of emphysema of the 
subcutaneous tissue of the neck, and even of the entire body, as a conse- 
quence of the free escape of air into the connective tissue of the lung, and 
th • the meflia.«»tinal spaces. It is therefore probable that, in cases 

01 , ^ which end favorably, but in which the paroxysms of cough 

have been severe, a less degree of emphysema occurs, which in most in- 
stances speedily passes away after the disappearance of the primary affec- 
tion. Indeed, as nearly all the children whom we have attended with 
hooping-cough, continue under our charge, and as only in a very few cases 
do any symptoms of emphy.«ema persi.st, we must conclude either that it 
less frequently attends pertussis than would naturally be supposed, or else 
that the lung-tissue soon regains its elasticity, and the overdistension of 
the air-vesicles disap[)ears. In some instances, and especially in those 
where chronic bronchitis follows the attack of hooping-cough, all the symp- 
toms of emphysema may gradually develop themsplvas. 

Vomiting is a verj' frequent incident in pertussis, but ought not to be re- 
garded as a complication, unless df|x*ndent on some disease of the digestive 
organ.?, or symptomatic of cerebral disease. Where it occurs in simple 
cases, or in those complicated with bronchitis or pneumonia, it has always 
seemed to us to he advantageous. 

Tuberculoeis and scrojula are not infrequently found to follow hooping- 



262 HOOPING-COUGH. 

cough, in cases where a marked predisposition to these conditions exists. 
The tuberculous affection is most apt to take the form of pulmonary or 
bronchial phthisis. These sequelae are frequently observed in hospitals, 
and among the ill-fed and feeble children of the poor, but are comparatively 
rare among the better classes of society. 

Diagnosis. — The diagnosis of pertussis is difficult only during the first 
stage of the complaint. It is impossible, indeed, to distinguish, during 
that stage, between it and simple mild laryngitis, or the mild catarrhal 
attacks which are so common in our climate. After it has once fairly en- 
tered upon the second stage, it is scarcely possible to confound it with any 
other malady. MM. Rilliet and Barthez state, however, that acute bron- 
chitis with paroxysmal cough is not unfrequently mistaken for pertussis, 
and we recollect perfectly having made this mistake ourselves, in a little 
girl, five years of age. The cough assumed so exactly the features of per- 
tussis, that after waiting a few days we announced, authoritatively, the 
presence of pertussis. Only three or four days after this we were forced 
to take it all back, for the whole thing had disappeared, bronchitis, per- 
tussis, and all. The patient was entirely well. But the mistake need sel- 
dom be made, if it be recollected that in acute bronchitis with paroxysmal 
cough, the invasion is sudden ; that there is violent fever, great dyspnoea, 
and the physical signs of bronchitis ; that the hoop is generally wanting, 
or feebly marked, and that the disease is violent and rapid in its course ; 
all of which circumstances are widely different from what occurs in per- 
tussis. 

The same authors assert that tuberculosis of the bronchial glands gives 
rise to a cough which may be mistaken for pertussis. The following table 
extracted from their work will show the differences between the two dis- 
orders : 

PERTUSSIS. TUBERCULOSIS OF THE BRONCHIAL 

GLANDS, 

Often epidemic, attacking several chil- Always sporadic; non-contagious, 
dren at once; transmissible by cmtagion. 

Three distinct stages, of which only the No distinct stages, 
second is accompanied by kinks. 

Kinks attended with hooping, ropy ex- Kinks generally very short, without 
pectoration, and vomiting. hooping, ropy expectoration, or vomit- 

ing- 
Pure respiration in the intervals between Physical signs of tuberculosis of the 
the kinks. ganglions; but, in certain cases, absence 

of these signs. 

In the intervals between the kinks, res- Accessions of asthma in some cases, 
piration and pulse natural, so long as the with the kinks; continuous febrile 
disease is simple. movement, with evening exacerbations, 

sweats, progressive emaciation, etc. 

Voice natural. Voice sometimes hoarse. 

Course generally acute. Chronic course. 

We would add that we have known the paroxysmal cough attendant 
upon the development of miliary tubercles in the lungs to simulate hoop- 
ing-cough so closely as to render it very difficult to distinguish them. In 



PROGNOSIS. 268 

one case where this resemblance was very great, the circumstances rendered 
the diagnosis additionally ditticult. The patient, the eldest of three chil- 
dren, had a perfectly well-marked attack of hooping-cough in his fourth 
year. Two years later, his little brother and sister contracted the disease 
in a marked form. Nearly at the same time, the eldest boy, then about 
six vears of age, was attacked with severe paroxysmal cough, recurring in 
kinks, often inducing vomiting, and occasionally terminating with a sort 
of hoop. Physical exploration of the chest yielded only negative results. 
Still our suspicions were aroused by the facts that a previous attack had 
occurred, that the hoop did not become so perfectly developed as in true 
hooping-cough, and that there were progressive emaciation and weakness 
to an unusual degree. In the second month of the cough, the symptoms 
of tubercular meningitis appeared, death ensued, and, at the autopsy, in 
addition to tuberculosis of the membranes of the brain, the lungs and spleen 
were studded throughout with numerous miliary granulations. In the 
meantime, the two younger children passed successfully through the stages 
of hooping-cough and entirely recovered. 

Proc;nosis. — Pertussis is rarely a dangerous or fiital disease so long as 
it remains simple. Of the 208 cases observed by ourselves, 143 were simple, 
all of which recovered. Nevertheless even the simple disease does some- 
times terminate fatally, from the excessive violence of the paroxysms of 
couirhing. 

The danger in ho4iping-cough, which is considerable, depends, therefore, 
almost entirely on the complications which are so apt to occur, for which 
rea^D the physician should watch with the closest attention, in order to 
prevent their occurrence, and that he may recognize and treat them in 
their earliest stages. The most dangerous complication is convulsions, 
and after that bronchitis and pneumonia. So long as the child seems well 
and lively, and without fever or dyspnoea, in the intervals between the fits, 
there is nothing to be feared. But if, on the contrary, it becomes languid 
and irritable, with indisposition to take food, feverishness, and some in- 
crease of the rate of respiration, the practitioner should be upon his guard. 
A very early age and natural delicacy of constitution, are unfavorable cir- 
cum.«tances in the disease. Some form of complication occurred in 65 of 
the 2<>8 ca^e^ observe*! by ourselves. Of the Go, 12 died. 

Five of the 12 fatal ca.«e8 ended with convulsions. Of these 5 cases, the 
convulsions were caused by bronchitis and collapse of the lung in 4, the 
fatal result being the consequence, in fact, of the lung complication. One 
of the cases wa.s independent, apparently, of disease of the lung (though, 
as no post-mortem examination was made, this cannot be asserted posi- 
tively), but seemed to be the result of the violent laryngismus, with con- 
tracture and general convulsions, such as will be described in the article 
on laryngismus stridulus. Two of the cases occurred in children of eight 
and nine months old, respectively, and proved fatal in twenty-four hours 
after the setting in of the convulsion.s. Two others occurred in children 
in their second year, and the fifth occurred in a boy between three and 
four yean old, and caused, death in seven hours. 

Of the remaining seven fatal cases, one was the result of collapse of 



264 HOOPING-COUGH. 

the luDgs, supervening suddenly upon a mild bronchitis, in a twin child 
between two and three mouths old. The second was caused by tubercular 
disease of the lungs, in a child between three and four years old, and the 
remaining five by bronchitis, associated, to a greater or less extent, in all 
probability, with collapse of the lung. Of the last-mentioned five cases, 
one occurred in a child between five and six months old, and was rapid in 
its course ; two occurred in children between one and two years old, one 
being rapid and the other lingering in its course; one occurred in the third 
year of life, and was attended with severe diarrhoea from teething, as well 
as with bronchitis and collapse ; and the fifth occurred in a child in its 
fourth year, and was slow and gradual in its course. To sum up, it may 
be stated that of the 12 fatal cases, 10 were the result of bronchitis and 
collapse, 1 of tuberculosis of the lungs, and 1 of laryngismus stridulus. 

Nature of the Disease. — There is no essential anatomical lesion in 
pertussis, except, perhaps, slight inflammation of the bronchial mucous 
membrane. In most of the cases, the membrane lining the larger and 
smaller air-tubes, and very rarely that of the trachea, is reddened and per- 
ceptibly thicker than natural, and the tubes contain a considerable quantity 
of frothy mucus, or a thick, viscid, and tenacious phlegm. 

As to the nature of the disease, it seems to us very clear that it ought 
to be regarded as comprising two elements of morbid action, one of which 
consists in slight inflammation of the respiratory mucous membrane, and 
the other of disordered action of the respiratory system of excito- motor 
nerves. It is neither a pure neurosis nor a pure inflammation, but par- 
takes of the characters of both, and much more of the former than of the 
latter. The authors of the Compendium de Medecine Pratique (t. ii, p. 
526) regard it as a neurosis, on the following grounds : " 1. In the greater 
number of cases the respiratory apparatus presents no kind of alteration, 
or else the lesions are so multiplied or variable, that they are surely not 
the real origin of the disease. 2. The clearly remittent course of the 
symptoms, and the total absence of fever, unless some complication is 
present, are not observed in ordinary or even specific inflammations. 3. 
The cessation or sudden return of the paroxysms, under the influence of 
moral emotions or change of place, belong to a disorder of innervation, 
and not to inflammation, which commonly passes through certain stages 
before it is resolved. 4. The complete return to health, the integrity of all 
the functions in slight cases, the resistance which it opposes to treatment, 
the uselessness of antiphlogistics, and the success obtained from narcotics 
and antispasmodics, are all so many circumstances peculiar to hooping- 
cough and to many of the neuroses." 

It has, however, so many points of resemblance to the various constitu- 
tional diseases, as its undoubtedly contagious nature, the facts that it runs 
a definite course, and that one attack protects the system against a second, 
that it also probably depends upon a morbid state of the blood, due to the 
introduction of some specific poison which possesses the peculiar power of 
irritating the pneumogastric nerves. 

Treatment of Simple Pertussis. — Hooping-cough, like all other dis- 
eases, varies greatly in its degree of severity. It is sometimes an afl^air of 



TREATMENT — BLOODLETTING. 265 

DO consequence scarcely, the patient passinjx through its stages without 
suffering, and without any injurious consequences whatever to the general 
health. We have known a large family of children to pass through the 
disease without other treatment than attention to a prudent hygiene, and 
with no other medicine than a few doses of a mild cathartic, given to re- 
lieve some uncomfortable gastric symptoms. We have known one child 
in a family where jhe disease was prevailing at the time, to have the cough 
for only five weeks, and to hoop only on two or three occasions, and to 
lose neither appetite nor spirits for a moment. Such cases evidently need 
no interference, and a wise physician will, in such, order no drugs. His 
business will be simply to direct that the child be guarded against cold 
and against imprudences in diet. 

In other instances the disease assumes, from a very early period, or 
sometimes not until later, a character of a very different kind. AVithout 
any complication whatever, the natural symptoms of the disease develop 
in great intensity. The spells of coughing are very frequent, very violent, 
and very long-continued. Instead of some twenty spells or less in twenty- 
four hours, as is the rule in mild and moderate cases, the patient will aver- 
age two or more every hour, having fifty or sixty spells in the day. The 
Iar}'ngismus, instead of being slight, will be violent and distressing, so 
that in lieu of three, four, or five hoops in a paroxysm, there may be four- 
teen or fifteen, and these so shrill, acute, and prolonged, as greatly to 
exhau.«t the poor little patient. Or the laryngismus may be so intense as 
to cloee for a few seconds the glottis, and arrest entirely the respiration, 
giving rise to the most painful attacks of struggling and suffocation pos- 
sible to behold. Or the vomiting may be so frequent as seriously to inter- 
fere with the nutrition of the child, and thus cause threatening and even 
dangerous debility. In certain families, and in certain epidemic types of 
the disease, it assumes these severe features, and such cases must take the 
same rank in this disease that grave cases of scarlet fever, measles, or 
variola, take in those affections. 

Cases of this latter kind imperatively demand treatment, and they are, 
we are happy to state, susceptible very generally of great and striking 
alleviation, by the use of proper means, — means, too, which in themselves 
are ver}* safe. 

At one time we were very much disposed, we confess, to avoid all inter- 
ference so long as we saw no complication in the case, under the suf)po- 
sition that the disease in its simple form wan always safe, and might be 
tnisterl to the efforts of nature. More enlarged experience has taught us, 
hf»wever, that tlie verj' violence of the disease, even in its simple form, 
was a source of danger; and that, moreover, such severe cases were much 
more liable than milder ones to complications, while a proper treatment, 
in-'tituted so soon an the disease began to show thcs(? severe characters, has 
almo<*t always, after a few days' perseverance, brought about and main- 
tained a most evident amelioration of the symptoms, thus keeping within 
due bounds a development which might otherwise have gone on to a dis- 
T!-' iiiatiftn. 

J, ,,y, — Depletion is very rarely necessary in simple pertussis. 



266 HOOPING-COUGH. 

The only cases in which it can be called for are those occurricg in SBrnguine 
children, where the laryngismus is so extreme and the paroxysms so vio- 
lent as to lead to great engorgement of the right side of the heart, and 
even to endanger the brain by overdistension of the veins. Under these 
circumstances, we might resort to venesection merely for the mechanical 
relief afforded, as recommended under similar conditions in pneumonia. 
In such cases only then, a small bleeding, or the application of a few 
leeches to the temples or behind the ears, may be proper ; but even these 
may generally be safely treated by reduced diet and by a few doses of 
saline cathartics, without a resort to the more powerful and more perma- 
nently exhausting means of depletion. As for the treatment of simple 
pertussis by repeated venesections, in the hope of curtailing its duration, 
or under the idea of their being rendered necessary by the violence of the 
malady, it seems to us forbidden by the present state of medical knowl- 
edge, which informs us that the greater number of the cases do not en- 
danger life so long as they remain simple, however violent they appear to 
be. Of the 143 simple cases treated by ourselves, depletion was not used 
in any, and all recovered. 

Narcotics and Antispasmodics. — Of the various remedies of this class 
which have been more or less extensively employed, the most important 
are belladonna, opium, and hydrocyanic acid. Assafoetida and, of recent 
years, several of the bromide salts have also been much used with apparent 
success. 

Belladonna is highly recommended by several German authors, by MM. 
Rilliet and Barthez, who state that it is beyond contradiction the one most 
deserving of confidence, by Trousseau and Pidoux, and by numerous Eng- 
lish and American writers. MM. Trousseau and Pidoux employ the fol- 
lowing formula : 

R. — Pulv, Belladonnse, . ' gr. iv. 

Extract. Opii Aquos., gr. iv. 

Extract. Valerianae, ^ss. 

M. et div. in pil no. xvi. 

S. One to four in the course of the day. 

If the child dislike the pilular form, they give it in syrup, according to 
the following formula : 

R.— Extract. Belladonnse, gr. iv. 

Syrup. Opii, ] 

Syrup. Flor. Aurantii, aa f^j. — M. 

Of this, from one to eight teaspoonfuls are to be given in twenty-four hours. 

We have ourselves used belladonna in a very large number of cases of 
hooping-cough, and with such unquestionable benefit, that we regard it as 
one of the most valuable remedies for this disease in our possession. 

We have certainly never seen it cut short the course of the disease as it 
has been asserted to do, but we have almost invariably found it to mode- 
rate the laryngismus, shorten the paroxysms and diminish their number 



TREATMENT — ANTISPASMODICS — EMETICS. 267 

and probably also shorteu the duration of the attack. We have not, how- 
ever, been in the habit of prescribing such large doses of bcUadiuma as 
those quoted above (gr. i) ; but have usually given it in combination with 
alum or with bromide of ammonium, in the dose of Tr^th of a grain of the 
extract, every four hours, to a child of one year old. The formula which 
we employ will be found in our remarks upon the use of alum, 

BeUadonna has also been largely used, especially by Dr. Fuller, in com- 
bination with sulphate of zinc, and with excellent results. This latter 
author states that he has observed a remarkable tolerance of belladonna 
in children, so that, be^rinning with quite large doses, the amount may be 
rapidly, though ciirefully, increased until the quantity taken exceeds out 
of all proportion the correspondingdoses which will be tolerated by adults. 
Even when given, however, in the comparatively small doses of rr'^th or 
f'jth of a grain, it is necessary to watch for any symptoms of the toxic 
action of the drug, so that its administration may be suspended or ihe 
amount diminished. 

Opium is confessedly a very valuable remedy in the disease, not as a 
curative, but as a sedative and palliative. When the cough is freijuent 
and fatiguing, especially if the patient have an irritable and nervous cou- 
stitutioD, some opiate preparation is of the utmost service in moderating 
the frequency and violence of the paroxysms, and in allaying irritability 
and restlessness. It is best given in the evening, and in combination with 
ipecacuanha. 

Hifdrocyanic acid has been employed by various observers, and is highly 
spoken of by some. Iti* poisonous properties, however, have deterred 
many, and amongst them ourselves, from resorting to it. Inasmuch as 
there are other and safer means for conducting the disease to a favorable 
termination, it seems to us useless to venture upon so potent a preparation 
as this. 

Since the discovery of the powerful antispasmodic properties of the va- 
rious bromiiUs, they have been much used in the treatment of this disease. 
The bromidr of ammonium has been recommended, especially by Clibb and 
G. Harley, a^ a pharyngeal and laryngeal anaesthetic, to diminish the 
spasm of these part*, while, at the same time, the alkali acts by rendering 
the secretion from the bronchial mucous membrane more free and readily 
expectorated. The bromide of potassfinm acts in the same way, and is pro- 
ductive, probably, of equally good results. We have used both of these 
M»its frequently, especially in combination with l)elladonna, and have ob- 
-- "' ' I marked reduction in the severity and number of the paroxvsms 
"I ' ^'ii in many of the cases. We have, also, used assafcctida in a num- 
ber of instances with decided benefit, both in relieving the general restless- 
ness and in moderating the number and severity of the paroxvsms. The 
d<^«'' in which we have given it are either two or three grains in pill, or a 
tea.-'p<K>nfuI of the mistura a-ssafcetidic, three or four times a day to a child 
of four years old. 

Emrticjt and Xauseants are amongst the most important remedies in the 
tr;:: nt of hooping-cough, sincc they exert a powerful influence upon 
t;i' '. -itse, and unless carried to excess, are not in themselves likclv to be 



268 HOOPING-COUGH. 

injurious. Some authors recommend the administration of an emetic 
every day or every other day, while others give them according to the ne- 
cessity of the case. Believing that frequently repeated emetic doses are un- 
necessarily severe, and productive of too much fatigue and exhaustion, we 
have preferred in the simple disease to give- only small doses of ipecacu- 
anha from time to time, so as to moderate the violence of the cough. Tar- 
tar emetic is never necessary, and ought to be avoided, on account of its 
disposition to irritate and inflame the gastro-intestinal mucous membrane, 
and because of its exhausting effects on the general economy. The syrup 
of ipecacuanha is the preparation we have almost always used. From ten 
to twenty drops, given three times a day to a child three years old, will 
very generally moderate the severity of the paroxysms. 

Purgatives are necessary in the simple disease only when constipation is 
present. The mildest ought to be preferred, in order to avoid irritation 
and exhaustion. Castor oil, magnesia, or syrup of rhubarb are the best. 

Particular Remedies. — Of the different specific remedies that have been 
employed, none have attained and maintained so high a reputation in 
this city as the carbonate of potassa, which, in the form of the cochineal 
mixture, is constantly used both by physicians and as a domestic remedy. 
The beneficial effects of this drug are equally recognized abroad, as may 
be judged from the language of Niemeyer, who, when speaking of its use 
in hooping-cough {op. cit., vol. i, p. 101), says, " Its effect in shortening the 
fits of coughing is often surprising." The following formula is the one 
generally administered : 

R. — Potass. Carbonat., 9J- 

Coccii, . . . . . . . . . ^ss. 

Sacch. Alb., 3J. 

Aquse Fontis, f,5iv. — M. 

Give a dessertspoonful three times a day to a child a year old. Believing 
the carbonate of potash to be the active agent in the mixture, we have 
generally left out the cochineal and used the potash alone, dissolving it in 
equal parts of syrup of gum and water. We have frequently employed 
this remedy, and believe that it, with alum and belladonna, are the most 
useful agents we have to keep down the violence of the disease. We have 
given it in the dose of a grain three or four times in the twenty-four hours, 
to children one and two years old, for several weeks at a time, without wit- 
nessing any injurious effects from it. 

Alum was first highly recommended as a remedy in pertussis by Dr. 
Golding Bird (Guy's Hospital Reports, April, 1845). He states that in 
the second or nervous period of the disease, when "all inflammatory 
symptoms have subsided, and when, with a cool skin and clean tongue, 
the little patient is harassed by a copious secretion from the bronchi, the 
attempt to get rid of which produces the exhausting and characteristic 
cough, alum will be found to be of much value." He adds, that he " has 
not yet met with any other remedy which has acted so satisfactorily, or af- 
forded such marked and rapid relief." From reading Dr. Bird's remarks 
on alum, and prompted by our knowledge of its admirable qualities in the 



TREATMENT — ALUM. 269 

treatment of croup, we were formerly led to make trial of it in the disease 
under consideration, and we believe we may say that it has exerted a more 
decideti iutlueuce in moderating the violence of the disorder, than any that 
we have ever made use of We have administered it in 139 cases, begin- 
uing in the course of the second stage. In nearly all it was beneficial, and 
in some the effects were strikingly useful, the improvement being more 
rapid than we had ever seen to result from other remedies, or to occur 
when the disease has been allowed to pursue its natural course. In a boy, 
between five and six years of age, who had been coughing violently for 
two weeks, the jiaroxysms diminished so much in intensity and frequency, 
after he had taken the remedy two days, that he was not once disturbed at 
night (though before he had always been waked several times), and the 
spells which occurred during the day were much less severe. After con- 
tinuing the remedy for ten days, the disease had subsided so much that its 
employment was suspended. Soon after, however, the paroxysms again 
became severe and troublesome. The alum was resumed, and with the 
same results as at firet. In another family in which there were three 
children all of whom had been taking syrup of ipecacuanha and carbon- 
ate of potash for some days, without any good effects, the alum was given 
and acted as in the case first referred to. The nights were comparatively 
quiet, and the spells occurring through the day very much moderated. 
We may repeat that, so far as our experience in the above 139 cases goes, 
the eff»*cts of alum have been more decided and satisfactory than those of 
any other remedy. We have never known it to produce ill-consequences, 
either at the time of its administration or subsequently, though we have 
given it to children from two months to seven years of age, and have con- 
tiDue<l iu use from one to six weeks at a time. It, like all other remedies, 
sometimes fails, however, to do any good, and when we have found tliis to be 
the case, we have substituted belladonna or carbonate of potash, either alone 
or combined, and it is curious to observe how, in some instances, the latter 
r» !!!• ii' s will succeed where the other fails. Nothing but a trial will .<how 
wlii< ii i> the most proper in any individual case. Of late years we have 
usually given the alum and belladonna together, and have been much 
pleased with the results. If administered in large doses, alum produces 
vomiting. It does not constipate, but on the contrary, is apt to induce 
diarrhua, when continued for some time. Dr. Bird gives from two to six 
grains every four hours. Ili.- formula is us fullows: 

B.— Aluminis, . . . gr. xxv. 

Ext. Conii, gr. xij. 

S^Tup. Kboeadoi, f ^ij. 

Aqu« Anethi, f5iij.— M. 

Give a medium -si zed spoonful every three hours. 

To children under one year, we give from half a grain to a gmiii, three 
or four times a day ; and to those over that age, two grains every four or 
six hours. The formula we have employed is the following: 

B.— Aluminia, B'j'"'- 

Syrup. Zingib., Syrup. Acaci«, Aqu« Fontis, aa, . f5J.— M. 



270 HOOPING-COUGH. 

When this is prepared with good syrups, it tastes very much like lemon- 
ade, and is not at all unpleasant, so that children take it without diffi- 
culty. The dose is a teaspoonful three times a day, or every four or six 
hours. 

As above said, however, we now generally employ a combination of 
alum and belladonna, and have obtained better results from it than from 
any single remedy we have ever used. For a child one year old we use 
the following formula : 

R. — Ext. Belladonnse, gr. j. 

Aluminis, ^ss. 

Syr. Zingib., Syr. Acacise, Aqute, aa . . . • f^j- 
M. et ft. sol. 
Dose, a teaspoonful four times in the twenty-four hours : in the morning, at noon, 
bedtime, and once in the night, if the cough be troublesome. 

Among other remedies which have been highly recommended, but which 
we have never found it necessary to resort to, may be mentioned the fol- 
lowing : 

Sulphur is much used by some German authorities, who greatly commend 
its effects both at the beginning and throughout the course of the disease. 
It may be given in powder diffused in milk or syrup, or in emulsion, in 
doses of three grains, two or three times a day, to children from two to 
four years of age. 

Subcarbonate of Iron has been successfully employed by Dr. Steyman and 
by Lombard, of Geneva. 

Dilute Nitric Acid, first recommended by Arnoldi, of Montreal, has been 
highly praised, especially by Gibb. 

Conium has also been frequently used, both alone and as an ingredient 
in formulse containing some of the other remedies here mentioned, and 
appears to alleviate the violence of the paroxysms, though to a less marked 
degree, we believe, than belladonna. 

Inhalations. — In was noticed in France, some years ago, that children 
suffering with hooping-cough, who lived in the neighborhood of gas-works, 
were rapidly cured ; and the plan has been recently tried with success, of 
sending patients with this disease to inhale the fumes arising during the 
purification of gas, which contain ammonia, vapor of tar, and several 
volatile oils. Dr. Bertolles {British Med. Jour., Nov. 5, 1864) states that 
"the register of the gas-works -at Ternes, shows that during the previous 
six months, 901 patients have been subjected to the vapor treatment, of 
whom 219 were cured and 122 relieved." M. Commerege (id. loc.) has 
also rei^orted the effects observed in 142 children who were brought under 
the action of the gases in the gas-works at St. Maude ; and believes that 
the treatment produces excellent results at all stages of the disorder. In 
general, twelve seances, each of which should be of two hours' duration, 
are required for the cure. We have ourselves known of quite a number 
of instances among the children of the poorer classes in this city, where 
patients, suffering with hooping-cough, have been allowed to inhale the 
fumes from the gas-works, and have experienced positive benefit. 



TONICS — TOPICAL APPLICATIONS. 271 

Tonics. — In a uumber of cases that have come imder our notice, the 
patieut has grown pale and weak in the course of the disease, and this 
without any local complication, but from the disturbance of the digestive 
system that ot\en exists to a greater or less extent, from the great frequency 
of the vomiting, which prevents them from taking a sufficient amount of 
nutriment, and from the exhausting etiect of the violent muscular exertion 
undergone during the paroxysms. In such instances, when there has been 
no fever, or merely a little evening febricula, we have employed tonics 
with much advantage, and never to the injury of the patieut. We have 
genenillv made use of Huxham's tincture of bark, either alone, in doses 
of from ten to twenty drops three times a day, or in connection with the 
gyrup of the iodide of iron, or half a grain of the metallic iron (Pulv. 
Ferri). When the appetite has been very feeble, we have found that 
quinine, in the dose of a grain three or four times a day, at the age of 
three or four years, has restored it more rapidly than any other remedy 
we have used. 

Local Applications. — Beimlsives. — The milder revulsives are useful 
in certain complications of pertussis, and as palliatives. To make them 
the chief basis of the treatment, however, which has been done by some, 
is a mistake. In order to produce a decided impression upon the disease, 
it would be necessary' to resort to the more powerful remedies of this class., 
wich as moxas, issues, tartar emetic ointment, blisters, etc., the use of 
which is not warranted by the nature of the disorder. 

When the laryngismus has been severe, we have known the use of a 
belladonna plaster, 2 by 3 inches, applied over the larynx and worn for 
several days, to afford relief. 

Tnj,lfiil applications to the interior of the larynx of solutions of nitrate 
of silver have been used by several practitioners, as by Gibb and Eben 
Watson, and apparently with much benefit. The strength of the solution 
should vary according to the stage of the disease, being much reduced 
during the early acute period. 

In case* occurring in older children, where the spasmodic irritability of 
the larynx is extreme, we may employ with advantage the inhalation, by 
mean.< of the atomizer, of the vapor of water, or of weak alkaline solu- 
tions, to which minute quantities of morphia may be added. 

Before concluding our remarks upon the treatment of simple hooping- 
cough, we wish to state that cases of the disease occur not unfrequently of 
.-'• mild a form, as to need al)solutely no treatment other than the proper 
df ;rrf»- of attention to hygiene ; and that others again, more numerous than 
tho-. ju.-*t mentioned, will be met with, in which the only treatment neces- 
sary is the u.«*e, for a few days or weeks, of some mild expectorant and 
opiate at night to lessen the severity of the paroxysms, or of moderate 
do-*-^ of alum, belladonna, or carbonate of potash. 

In infants particularly it is proper to give as little medicine as possible, 
allowing the disease to go on without interference so long as it progresses 
safely. In a good many mild cases, small doses of paregoric and syrup of 
ipecacuanha, constitute the only remedies we have found necessary in the 
cases of infants. When, however, the j>aroxysms become numerous and 



272 HOOPING-COUGH. 

violent, exhausting the strength of the child and distressing its nervous 
system, we must make use of some remedy to allay the severity of the 
attacks. We have found the alum and belladonna formula recommended 
above safe and effectual. At the age of two and three months, we have 
usually given from half a grain to a grain of the former, combined with 
oVth grain of extract of belladonna, three times a day, taking care to sus- 
pend it for a day or two if it caused troublesome vomiting or purging, and 
then resuming it in diminished dose. Or we have made use of a quarter 
or half a grain of carbonate of potash, also combined with the twenty- 
fourth part of a grain of the extract of belladonna, three or four times a 
day. 

Treatment of the Complications. — If any of the diseases which 
have been mentioned as apt to occur during the course of pertussis should 
arise, the treatment which is proper for them in their idiopathic form must 
be adopted without regard to the hooping-cough, with the following reser- 
vation : that care must be taken not to use means of too powerful and 
exhausting a nature, or such as have a tendency to irritate the organ with 
which they come in contact. For, it must be recollected, that after the 
complication is cured, the patient has still the original disease to go through 
with, and therefore requires all his strength ; and moreover, the various 
organs of the body are predisposed, by the very fact of the existence of 
the original malady, to assume diseased action, should any irritation in the 
shape of a violent remedy be applied to them. 

The cases of bronchitis which came under our observation were treated 
in the simplest manner. The children were put to bed, the diet carefully 
regulated, the bowels gently opened with castor oil or syrup of rhubarb, 
and small doses of syrup of ipecacuanha or antimonial wine, with sweet 
spirit of nitre, were administered every two hours. Mustard poultices 
were applied once or twice a day to the interscapular space, and mustard 
foot-baths used every night, or more frequently, if the dyspnoea were con- 
siderable. If the bronchial secretions were very profuse, and the cough 
troublesome, the decoction or syrup of seneka was given in connection with 
occasional doses of laudanum or paregoric. 

The treatment of collapse of the lung should be that which is recom- 
mended in the article on that subject, modified, of course, as may be ren- 
dered necessary, by the existence of the hooping-cough. A mild emetic, 
if the patient seem strong enough to bear one; counter-irritants, and espe- 
cially sinapisms or mustard poultices applied to the chest, nutritious food, 
and mild stimulants, as brandy, wine-whey, tincture of bark, quinine, or 
aromatic spirit of ammonia, must form the principal means of treatment. 

The complication of pneumonia should be treated somewhat differently. 
At the present time we should advise the use either of the combination 
of sulphurated antimony and Dover's powder, or of one of the alkaline 
mixtures, recommended in the article on pneumonia, in conjunction with 
external applications and the use of the foot-bath ; and should not resort 
to bleeding, whether local or general, unless the indications, elsewhere laid 
down as calling for depletion in pneumonia, should be present in a marked 
degree. Indeed, in such cases, the early use of moderate stimulation and 



1 



TREATMENT OF THE COMPLICATIONS. 273 

of full tonic doses of quiuia is apt to be indicated on account of the te*n- 
dencv to depression. 

When couviiisions occur they must be treated according to the cause 
which produces them, and the consititution and present state of the child. 
If the patient be strong and sanguine, and not exhausted by previous 
sickness, the treatment should consist of depletion by leeches to the tem- 
ples, or behind the eai*s ; of cold applications to the head; the warm 
bath; large doses of bromide of potassium by the mouth or by enema; 
cathartics or purgative enemata; and revulsives in the form of sinapisms, 
or of a small blister to the nucha. If, on the contrary, the ]^atient is of 
delicate constitution, or exhausted by long illness, and especially when the 
convulsions are the result of extensive collapse of the lungs, occurring 
spontaneously or supervening upon bronchitis, we must be content to resort 
to warm baths, revulsives, antispasmodics, and anodynes, stimuli, and 
stimulating enemata. 

Of the 12 cases of convulsions that came under our notice, 5 proved 
fatal. Two of the fatal cases occurred in children who had long been 
laboring under bronchitis, probably associated with collapse', that had baf- 
fled all treatment. Death took place within twenty-four hours from the 
appearance of the convulsions, which were in fact the result of the diseased 
condition of the lungs. No treatment further than the warm bath and 
sinapisms, was resorted to. In the third case, the convulsions came on in 
the seventh week of the disease, in a child who had been laboring for a 
number of days under severe bronchitis; they ended fatally in seven hours. 
The treatment employed at the beginning of the fit was a w^arm bath, an 
enema, and mustard plasters. After a few hours, solution of morphia with 
fluid extract of valerian were given by enema, cold was applied to the luvid, 
and a blister to the nucha. In the f(mrth case, which occurred in a child 
in the .second year of its life, they were caused by bronchitis and collapse, 
and proved fatal in two days. The treatment consisted in the use of warm 
baths, counter-irritant*, alum, and small doses of brandy. The fifth case 
likewise occurred in thesecond year. This was one in which all the symp- 
toms of laryngismus stridulus — prolonged laryngismus, contracture, and 
general convulsions — were added to those of the primary disease. It was 
treated with belladonna, opium, assafnetida, and warm baths, but all to no 
eff*ect. 

Of the favorable cases, one occurred in a boy five months of age, on the 
third day of a severe attack of bronchitis. The child was immediately 
placed in a warm bath, and large sinapisms applied over the front of the 
chest and upon the extremities, when the convulsions ceased. After tliis 
he wa.« treated with half-grain doses of alum, repeated every three or four 
hours, mustard foot-baths, and poultices, and small doses of wine of opium. 
On the sixth day of the attack, the third after the convulsive seizure, there 
having been no return of the ronvulsions, tin; bronchitis sub-id**! with 
copious sweats and cold hands and feet, for which small quaMtities of 
brandy and water and wine-whey were used. The recovery was perfect. 
A second case occurred in a hearty boy nine months old, and sei^mcd to 
depend on congestion of the brain, brought on by a severe fit of coughing. 

18 



274 HOOPING-COUGH. 

lu this iustance a venesection to a small amount was performed, the child 
was placed in a warm bath, and cold applied to the head. No return of 
the spasms took place, and the child recovered without difficulty. In 
another case the convulsion was caused by an attack of fever depending 
on dentition, and was treated by lancing the gums, by a warm foot-bath, 
and by the administration of a grain of calomel in a teaspoouful of castor 
oil. In the fourth case the convulsions were caused by pneumonia, and 
were managed by treating the pneumonia, except that at the moment of 
the attack a warm bath and a stimulating enema were made use of. In a 
fifth the convulsion, which was a short one, occurred at the onset of an 
attack of bronchitis. No particular treatment beyond what was necessary 
for that disease was required. In a sixth, in a boy nine months old, the 
convulsion occurred suddenly, was violent, and lasted fifteen minutes. 
The cause could not be ascertained. The only treatment used for the con- 
vulsion was a warm bath. There was no return. In a seventh case, in a 
boy nine months old, a slight convulsion occurred during one of the par- 
oxysms in the fifth week. No treatment was necessary, as the attack was 
very short, and there was no recurrence of the symptoms. 

Hygienic Treatment. — This part of the management of the disease is 
of the highest importance, for it is by careful attention to its details that 
the complications which constitute the chief danger of the malady are to 
be prevented. In a considerable number of cases of pertussis, nothing 
more need be done than to insist upon strict attention to hygienic rules. 
The chief indications are, to preserve the child from taking cold, and to 
prevent indiscretions in diet. The clothing ought to be warm, and during 
the autumn, winter, and spring, flannel should always be placed next to 
the* skin. The child ought to be kept in the house during damp weather 
at all seasons, and whenever, during the winter season, it is intensely cold. 
The diet should be nutritious, but of easy digestion. All heavy, rich food 
ought to be absolutely forbidden during the continuance of the malady. 

Treatment of the Paroxysm. — It often happens that the paroxysms 
are so violent that the child seems to be in imminent danger of suflTocation 
or of convulsions. This is especially true of infants. In six cases that we 
have seen, in infants under six months old, the kinks lasted so long, and 
the spasm of the larynx was so unyielding, that the children struggled as 
though laboring under tetanus; the countenance was disturbed and anx- 
ious ; the face and hands, at first flushed, became purple from deep con- 
gestion ; and on some occasions the breathing was suspended for several 
seconds, so that life seemed for the time in the greatest danger. The diffi- 
culty in these cases depends on the spasmodic closure of the glottis, which 
is sometimes, no doubt, completely shut. We have never known these 
alarming symptoms of asphyxia to occur when the hoop has been clear 
and distinct, for when that is present, the larynx cannot be very tightly 
closed. 

When the symptoms above described occur in a child several years of 
age, the patient should be raised and supported in the sitting posture ; 
when in an infant, the child ought to be held lightly in the arms, so that 
it may take any position which instinct prompts it to. At the same time, 



TREATMENT OF THE PAROXYSM. 275 

cold water ought to be spriukled from the fiugers upon the face, the child 
shouUl be gently fimned, or, if the weather be warm, taken to the open 
window ; and if there be time, it is well to put the feet into mustard-water. 
It has been recommended on such occasions to apply compresses dipped 
into cold water to the sternum. We would propose the trial of a moans 
which the late Dr. C. D. Meigs found very successful in arresting tonic 
spasm of the respiratory muscles, in a case of laryngismus stridulus. This 
is the sudden application of a piece of ice wrapped in linen to the epigas- 
trium. When the laryngeal spasm is very intense and obstinate, a bella- 
donna plaster, as before recommended, or a small blister to the front of the 
neck, may be useful in controlling it. 

M. Bell speaks very highly of the results obtained by sprinkling a little 
ether on the clothes of the patient at the onset of the paroxysm ; and Dr. 
Churchill ( Di>ieaj*es of Childhood, p. 223), who has tried ether in 12 or 14 
cases, and chloroform in 6, regards it as a valuable addition to our reme- 
dies. He directs that about half a drachm of sulphuric ether should be 
spilled on the nurse's hand and held before the child's nose and mouth at 
the commencement of a tit of coughing. In only one or two cases no bene- 
fit accrued, while in others great mitigation of the spasm, and in three or 
four almost complete relief followed when the ether was thus applied. We 
should certainly recommend a trial of this procedure, making use, how- 
ever, from preference, exclusively of the sulphuric ether. 



CLASS IL 

DISEASES OF THE CIRCULATORY ORGANS. 
ARTICLE I. 

CYANOSIS. 

Synonyms; Definition. — This peculiar condition, known under the 
various names of Morbus Coeruleus, or the blue disease, and Cyanosis, may- 
be defined as a permanent state of lividity or blueness of the skin, depend- 
ing upon numerous malformations or derangements of the heart and great 
vessels. 

In a comparatively slight degree, this condition attends many of the 
chronic organic diseases of the circulatory organs ; and is also transiently 
present in the course of some acute diseases ; but under neither of these 
circumstances does the lividity merit consideration as a separate affection, 
being merely due to the imperfect oxygenation of the blood. 

There is, however, one form of cyanosis which we have occasionally met 
with that merits a special reference. In these cases, the blueness of sur- 
face has appeared from three or four days to as many weeks after birth, 
has been intense in its degree, and associated with marked disturbance of 
respiration, and yet, under proper treatment, the infants have usually re- 
covered. AVe believe that the cause of such cyanosis is to be found in 
atelectasis of the lungs, which acts partly by causing general venous con- 
gestion, and partly perhaps by obstructing the flow of blood through the 
pulmonary artery, so that the right cavities of the heart become over- 
distended, and there results an admixture of venous and arterial blood 
through the still unclosed foramen ovale. 

Before attempting to explain the peculiar blue color in cases of true 
cyanosis, it will be convenient to allude to the various lesions which have 
been found present in such cases. 

Morbid Anatomy. — The blood in cyanosis is dark, and contains an 
excess of carbonic acid ; it has also lost, to a great extent, its coagulability. 
The only organs beside those of circulation which present lesions, with any 
constancy, are the lungs. 

Dr. J. Lewis Smith (Dis. of Infancy and Childhood, 1869, pp. 578-599), 
who has studied this disease with great care, and collected all the cases of 
it upon record, finds the condition of the lungs recorded with more or less 
minuteness in 110 out of 191 cases. In 26 cases there was tuberculosis, 
either confined to the lungs, or chiefly exhibited in these organs ; in 35 



CYANOSIS — MORBID ANATOMY. 277 

cases the lungs were of small size, either from compression by effusion in 
the pleural sacs or pericardium, or sometimes, apparently, from the per- 
sistence of the fa?tal state over a greater or less portion of the organ. lu 
35 cases the lungs presented a dark color, owing either to atelectasis or to 
engorgement and congestion. In 9 there was emphysema in a part of the 
lungs; in 2, pneumonia; in 2, the color was pale; in 1, a bright crimson; 
in 1, the lungs were larger than natural ; in 1, the right lung was absent; 
and in 17, these organs were recorded as healthy. 

There is also found, in a large proportion of cases, venous congestion of 
the brain, liver, or kidneys. By far the most marked and important 
lesions, however, are those of the heart and great vessels, which are, ex- 
cepting in extremely rare instances, the essential seat of the disease. The 
number of these lesions already recorded is considerable, as will be seen 
from the subjoined table, borrowed from Smith, which shows their char- 
acter and relative frequency. 

1. Pulmonary artery absent, rudimentary, impervious, or par- 

tially obstructed, 97 

2. Rii^bt auriculo-ventricular orifice impervious or contracted, 5 

3. Orifice of the pulmonary artery and the right auriculo-ven- 

tricular aperture impervious or contracted, ... 6 

4. Right ventricle divided into two cavities by a supernumerary 

septum, 11 

5. One auricle and one ventricle, ...... 12 

6. Two auricles and one ventricle, ...... 4 

7. A single auriculo-ventricular opening; interauricular and 

interventricular septa incomplete, ..... 1 

8. Mitral orifice closed or contracted, ..... 3 

9. Aorta absent, rudimentary, impervious, or partially ob- 

structed, .......... 3 

10. Aortic and the left auriculo-ventricular orifices impervious 

or contracted, ......... 1 

11. Aorta and pulmonary artery transposed, . . . .14 

12. The cavae entering the left auricle, 1 

13. Pulmonary veins opening into the right auricle, or into the 

cavae or azygos v^ins, ....... 2 

14. Aorta impervious or contracted above its point of union with 

the ductus arteriosus; pulmonary artery wholly or in part 
supplying blood to the descending aorta through the ductus 
arteriosus, 2 

162 

It is evident from a glance at this table, that the vast majority of the 
above lesions must occur before the full development of the heart is 
attained ; and that consequently, in nearly every instance, cyanosiH is a 
congenital affection. But further than this it will be obnervcd, that in 
the first four groups in {Smith's table, or in 119 out of 102 rascn, the lesions 
affect the right side of the heart, and are precisely of the kind that we 
know are caused by inflammation of the endocardium. Bearing in mind 
then the well-a.«certained law, that cndrK-arditis occurring during fa-tal life, 
almost exclusively attacks the right hide of the heart, we can readily un- 



278 CYANOSIS. 

derstand how such lesions could be produced by au attack of iuflamma- 
tion affecting either the valves of the pulmonary artery, or the tricuspid 
valves, or some part of the lining membrane of the right ventricle. Should 
such an attack of endocarditis occur after the development of the cavities 
and septa of the heart, and the closure of the foramen ovale and ductus 
arteriosus, and lead to occlusion of the orifice of the pulmonary artery, it 
would of course be impossible for life to be sustained. But w^here such a 
lesion is produced while the interauricular and interventricular septa are 
still imperfect, and the ductus arteriosus patulous, so much compensation 
may be effected that life can often be prolonged for many years. Thus, it 
is evident, that the first effect of the closure of the orifice of the pulmonary 
artery, at such an early period, will be to cause a large portion of the 
blood from the right ventricle to pass directly through the opening re- 
maining in the interventricular septum into the left ventricle. Usually 
this opening is not free enough to relieve the right ventricle entirely, and 
there is consequently pressure exerted backwards on the blood entering 
from the right auricle, which forces' part of it through the foramen ovale 
into the left auricle, and thus still further relieves the fulness of the right 
cavities. As there is no outward current through the pulmonary artery, 
owing to the occlusion of its orifice, blood flows back into this vessel from 
the aorta through the patulous ductus arteriosus, and thus supplies 
the lungs. At the same time the bronchial arteries become much en- 
larged, and, in some rare cases, blood has been able to reach the lungs 
through abnormal branches from the internal mammary or intercostal 
arteries. In cases of cyanosis which prove fatal very soon after birth, the 
most diverse and inexplicable lesions, as before enumerated, may be 
found ; but in those instances where life is prolonged, the heart is usually 
found to present the associated lesions above described : contraction or 
occlusion of the orifice of the pulmonary artery, imperfect interventricular 
septum, and patulous foramen ovale and ductus arteriousus. In such cases, 
when the compensatory communications between the right and left side of 
the circulation are free, life may be prolonged for many years. 

This was very nearly the condition found in the following case,^ the 
opportunity of examining and describing which we owe to the courtesy of 
Dr. C. H. Thomas. 

" The patient was a young man, set. 22 years, who had been markedly cj^anotic 
from infancy, and was poorly developed. He was unable to maintain a proper 
temperature. He suffered constantly from slight dyspnoea, with occasional exacer- 
bations. At the autopsy there was marked congestion of the abdominal viscera, 
and the gall-bladder was packed with gallstones. Both lungs contained numerous 
yellow miliary tubercles. 

" The heart was rounded. The cavities of the ventricles were not much en- 
larged, nor was there any hypertrophy of the walls of the left ventricle. The walls 
of the right ventricle were, however, decidedly thickened, though not equalling 
those of the left. The septum ventriculorum was disproportionately thick, and 
terminated about one-third of an inch below the level of the origin of the aorta 

1 See Descriptive Catalogue of Path. Museum of Penna. Hosp., 'No. 1501, p. 84, 
by William Pepper, M.D. 18t59. 



MORBID ANATOMY — ILLUSTRATIVE CASES. 279 



in a smooth, rounded edge, over which the endocardium was thickened. The 
septum also seemed inside of its normal position, so as almost to bisect the aortic 
orifice. The aorta, which was slightly dilated but quite healthy, thus communi- 
cated freely with both ventricles. The origin of the pulmonary artery was very 
much obstructed, owing to coalescence and contraction of its valves The ductus 
arteriosus was, unfortunately, not preserved, but, owing to the largp size of the 
pulmonary artery beyond the seat of obstruction, it had in all probability remained 
patulous. The foramen ovale was closed." 

In this instance, the orifice of the pulmonary artery not being entirely 
closed, the opening in the interventricular septum had been large enough 
to allow the right ventricle to relieve itself in that way, and consetjueutly 
the foramen ovale had closed. 

When writing of atelectasis pulmouum (p. 137) we called attention to 
the fact that in some cases, where the state of imperfect expansion per- 
sistetl, the continued obstruction to the pulmonary circulation was followed 
by the same train of lesions, viz., patulous ductus arteriosus and foramen 
ovale, and dilated hypertrophy of the right side of the heart, as are con- 
sequent upon obstruction of the orifice of the pulmonary artery, and 
which, as in the latter case, might be attended with cyanosis. 

The mere |>ersistence of the foramen ovale can scarcely be regarded as 
a cause of |>ermanent cyanosis. It is quite possible that during the early 
days of extra-uterine life, a certain amount of cyanosis might exist owing 
to the admixture of venous and arterial blood allowed by this opening, but 
after the forces of the circulation become equalized, it is quite certain that 
the valve of the foramen may remain unattached, or may even be some- 
what insufiicient to close the opening, and yet no cyanosis be present. 

As an illustrative ca.se of one of the rarer forms of cyanosis, and one 
which bears in the most interesting manner upon the theory of its produc- 
tion, we abstract the following from a more full account published in the 
Proceedings of tJie Pathological Society of Philadelphia? 

The child was a well-developed male, born at full term. No discoloration was 
noticed at birth, but on the twelfth day, as the grandmother was preparing to wash 
it, it bad a convulsion, and from that time presented coldness of the extremities, 
gradually increasing lividity, feeble and rapid pul.-e, and moaning and sighing 
respiration. 

During inspiration, the sternum and upper parts of the chest were elevated, but 
the lateral regions remained unexpanded, and there was marked recession of the 
base of the thorax. The percussion-resonance was diminished on both sides, but 
esp<-cially on the right. The ve.-icular murmur was puerile, except over the right 
side, whore it was feeble. The cardiac sounds were decidedly louder at the right 
scapula than over the left. The cardiac impulse at the left nipple was very indis- 
tinct, and the sounds there feeble but natural. On pressing two fingers lightly to 
the left of the ensiform cartilage, close to the costal cartilages, a very di-tinrt and 
quite vigorous impulse could be felt, one much more di^tinct than at the nipple. 
At this point, a distinct blowing sound attended the systole of the heart. The diag- 
nosis made at the time wa« : atelectjisis of both lungs, of the right greater than of 

» Transposition of the Arteries. Dr. J. F. Meigs Proc. of Path. Soc., vol. ii 
p. 37; and Am. Jour, of Med. Science*, vol. xi, 1800, p. 416. 



280 CYANOSIS. 

the left ; dilatation with hypertrophy of the right ventricle ; obstruction of the 
pulmonary artery, and open foramen ovale. Death occurred on the forty-fourth 
day after birth. 

At the autopsy, the body was very small and thin. The thorax was flattened 
laterally, and contracted at the base. There was marked collapse of the lower 
lobes of both lungs, and especially of the right. The heart was one-half too 
large, and full, rounded, and distended with soft black clots. The walls of the 
right ventricle were very thick, and its cavity quite small ; it presented the ap- 
pearance we usually associate with the left ventricle. The walls of the left ventri- 
cle were thinner than those of the right; and its cavity was much more capacious 
than that of the right. The right auricle was dilated and considerably larger 
than the left. The foramen ovale presented an opening at its lower aspect of 
about 2 or 3 lines in diameter. The orifices of the venae cavse appeared smaller 
than usual. 

The aorta and pulmonary artery were transposed. The aorta arose from the 
right ventricle in the usual position of the pulmonarj^ artery; the pulmonary 
artery arose from the left ventricle, and passing under the arch of the aorta, gave 
to the latter, just beyond the left subclavian, the ductus arteriosus, which was 
quite pervious and of considerable size. The valves of the heart were healthy 
and not transposed. The pulmonary artery was of the natural size, and presented 
no obstruction at its point of origin. After giving oflf to the aorta the ductus ar- 
teriosus, it divided as usual into two pulmonary branches, which soon subdivided 
into others. 

The aorta was of full size and presented nothing unusual. It gave off at its 
arch the innominate artery, and then the left primitive carotid and the left sub- 
clavian. Just beyond the latter it received, from the pulmonary artery, the ductus 
arteriosus. 

The pericardium was normal in all respects. 

Theories as to the Production of Cyanosis. — -In the vast majority of cases 
the malformation which causes cyanosis is of such a character as to allow 
admixture of the venous and arterial blood, and, at the same time, to 
interfere more or less with the circulation of this mixed fluid. Ever 
since the time of Morgagni, authors upon this subject have been divided 
in opinion as to whether the coloration of the skin were due exclusively 
to one or the other of these causes : obstruction to the cardiac circulation 
and consequent venous congestion, or intermingling of the venous and arte- 
rial blood. 

In regard to the first of these causes, although it has numbered among 
its advocates Morgagni, Louis, and Stills, it cannot be considered com- 
petent to fully explain all the cases and peculiarities of cyanosis, al- 
though such central obstruction will unquestionably aid in its production. 

Nor can the second theory be held exclusively sufficient, since not only- 
are there cases met with where cyanosis is present and yet no admixture 
of venous and arterial blood is possible, but also, on the other hand, 
where a considerable degree of admixture exists without the production 
of cyanosis. 

It seems necessary, therefore, as Smith has clearly pointed out, that any 
theory which pretends to embrace all the elements of this complex condi- 
tion, should embody a reference to the fact that the essential defect in 
cyanosis is a want of arterialization of the blood. 

Symptoms. — Even in cases where cyanosis is due to congenital organic 



SYMPTOMS. 281 

lesioDS, the peculiar symptoms are not always present until some time after 
birth. 

Thus, in 138 of the eases of cyanosis collected by Smith, the time at 
which lividity was first noticed is stated as follows : 

In 97 it was within the first week, and often within i\ few hours after birth. 
In 3 at 2 weeks. In 6 from 2 to 5 years. 

*' 2 " 1 month. " 6 " 10" 20 " 

" 7 from 1 to 2 months. " 1 " 20 " 40 " 

" 5 " 2 '• t) •' " 1 over 40 years. 

" 5 " 6 '* 12 " — 

«' 3 «' 1 " 2 years. 41 

Dr. Smith adds, " that in these 41 cases, in which blueness did not occur 
till after the age of one week, if the patient were less than two years old 
when it commenced, there was frequently no obvious exciting cause; but 
above this age, with three exceptions, such a cause is known to have been 
present. It is interesting to observe how trivial the exciting cause fre- 
quently is " (an acute attack of sickness, an attack of convulsions, difficult 
parturition, a fall, or even a severe blow), " and equally interesting to note 
how long patients have enjoyed good health, not having the least lividity, 
although the anatomical vice, to which the final development of cyanosis 
was due, had existed from birth." 

The most characteristic symptom of cyanosis is the lividity of the sur- 
face, which varies in different cases from mere duskiness to a deep purplish 
tint. This color also varies in degree in different parts of the body, being 
most marked in the distant and especially the dependent portions, upon the 
mucous membranes, and wherever the capillary vessels are abundant, as on 
the face. Its degree varies, finally, in the same case with the condition of 
the circulation. In slight cases, when the patient is quiet and the circu- 
lation tranquil, the discoloration of the surface may be imperceptible, but 
upon any exertion, and especially in the more severe cases, the lividity 
becomes much intensified. In some instances, such as that narrated by us 
below, there may be actual ecchymoses of the surface, as in purpura. 

The .state of the general nutrition is much impaired, and the subjects of 
this di.*ea.se are usually stunted and illy developed. In many instances 
the generative system appears even more imperfectly developed than the 
rest of the economy. The temperature of the body is always reduced, and 
exposure to cold is ver}' poorly borne. 

In a good many cases the thorax presents the deformity .«o often found 
in a.«.soriation with rickets, known as the " pigeon-brea.st." It usually hap- 
pens, also, that the ends of the fingers and toes become bulbous. Distur- 
bances of the circulation and respiration are of frequent occurrence. Thus 
there is oflen .«ome abnormal bruit heard in the cardiac region, duo to the 
abnormal condition of tlie heart. The pulse may be regular and of fair 
volume, but more frequently is small, irregular, or intermittent, and palpi- 
tation is \ery readily induced by exertion. The disturbance of respira- 



282 CYANOSIS. 

tion usually corresponds in degree with the embarrassment of the circula- 
tion. 

While the patient remains quiet his breathing may be easy and regular, 
but usually any sudden movement or exertion or emotion is sufficient to 
induce a paroxysm of dyspnoea, during which the lividity of surface be- 
comes much deeper. In infants these paroxysms not rarely terminate in 
convulsions. Headache is frequently complained of, and is very apt to 
be caused by whatever disorders the circulation. During the paroxysms 
of palpitation, pain is often complained of in the region of the heart, but 
is rarely persistent. 

Owing to the extreme venous stasis frequently present, there is a tendency 
to passive haemorrhages in cyanosis, which expresses itself by bleeding from 
the nose, mouth, stomach, or rectum, or under the skin. (Edema of the 
lower extremities is often met with as a temporary condition after long 
standing on the feet ; it is also apt to appear and to invade the rest of the 
body towards the close of the case, when the circulation becomes more en- 
feebled. 

Modes of Death. — Many cyanotic patients die from the effect of some 
intercurrent acute disease, as hooping-cough or one of the exanthemata, 
all of which are very badly borne in this condition. 

The theory that venous congestion is opposed to the development of 
tuberculosis, was applied by Rokitansky to this affection ; but without any 
sufficient ground, since, as we have seen already, tuberculosis was found as 
the cause of death in no less than 26 of the cases collected by Dr. Smith. 

In other cases death occurs suddenly, either daring an attack of convul- 
sions or a paroxysm of dyspnoea. 

In severe cases of cyanosis life is rarely prolonged more than a few 
years ; but in less marked cases the patients may even attain middle age. 
In 186 cases collected by Dr. Smith, the age at death was as follows : 

In 17 under age of 1 week. In 21 from 5 years to 10 years. 

" 10 from 1 week to 1 month. " 41 " 10 " " 20 " 

" 12 " 1 month to 3 months. '' 20 " 20 " " 40 '* 

«' 11 " 3 months to 6 " " 4 over 40 years. 

u 17 u 6 u u 12 " 

" 12 " 1 year to 2 years. 186 

" 21 " 2 years to 5 " 

So that in 67, or more than one-third, death occurred before the close 
of the first year; in 121, or more than three-fifths, before the age of 10 
years ; only 24 survived the age of 20 years, and 4 the age of 40 years. 

We subjoin the history of a case of cyanosis which we had under obser- 
vation for several years, in which the symptoms of this peculiar condition 
were extremely well marked. 

J. W., set. 16 years and 7 months, has been cyanotic since infancy, but for the 
past few years, at least, has enjoyed fair health. At present there is marked lividity 
of the lips and of the nose, especially at the extremity, which seems somewhat in- 
creased in size. His hands habitually appear as though stained with solution of 
carmine, the skin being uniformly livid over the whole hands, but becoming lighter 
colored on the forearms. Pressure partly removes the lividity, which returns 



TREATMENT. 283 

slowly after the withdrawal of the pressure. At times there have been little ecchy- 
nioses of the surface, followed by the etJusion of serum under the epidermis, and the 
formation of superficial excoriations, which have left small cicatrices. Only a few 
of these have appear«Mi on the hands. 

Those vascular disturbances are. even more marked in the lower extremities. 
The feet are continually deeply livid; and over their surface and the ankles, very 
numerous ecclu-motic spots have appeared, which underwent the same changes as 
those en the hands, and have left shining cicatricial spots, of a deep blarkish-red 
color from the deposit of pigment, and surrounded b\' a dark brownish stain. 
There has also been a good deal of oedema of the feet lately. All of these condi- 
tions have been improved by the use of tight-laced stockings. The skin of both 
the hands and feet is rather soft and moist. The last phalanges, both of the fingers 
and toes, are markedly clavate and hypertrophied. Firm pressure upon them re- 
duces their size; but, upon withdrawal of the pressure, the blood slowly returns, 
and they regain their former size. The temperature of the body is always low, and 
he suffers extremely from exposure to cold. 

He suflers somewhat from dyspnoea, even upon slight exertion, but less so than 
formerly. He is also troubled with cough during the winter months. There is 
marked deformity of the thorax, the first and second pieces of the sternum uniting 
at an obtuse angle, and the cartilages of the third, fourth, fifth, and sixth ribs, 
forming a marked prominence on either side of the sternum ; the ensiform cartilage 
is considerably depressed. 

The apex-beat of the heart is in the fifth costal interspace, and just inside of the 
vertical line of the nipple. The heart's action is regular, and at present there is no 
abnormal cardiac murmur, though two years ago there was a distinct soft systolic 
bruit. The pulse in the standing posture is 114, in the sitting, 108. He has occa- 
sional attacks of epistaxis, and sufi'ers quite frequently from attacks of gastric dis- 
turbance attended with severe headache. 

The above note was taken in December, 1869. Since our last edition, 
this case has terminated fatally, and a post-mortem examination proved 
the existence of marked congenital malformation of the heart, of the char- 
acter already fully described, originating evidently in obstruction of the 
pulmonar)^ orifice. 

Treatment. — In the form of cyanosis which we have described as de- 
pending on collapse of the lungs, the child should be placed in the position 
below recommended as rendering the heart's action most free; the temper- 
ature of the body should be carefully maintained, and a few doses of brandy 
in water or breast-milk should be given at intervals. There is evidently 
but little good that can be done by mere medication in cyanosis depending 
on malformations of the heart. When the heart's action is feeble and 
irregular, digitalis, iron, and quinia, may be administered. During the 
paroxysms of palpitation and dysj)n(ea, the best remedies are diffusible 
stimulants, such as Hoffman's anodyne, spirit of chloroform, ammonia, and 
brandy; and derivatives, such as sinapisms to the chest or hot mustard 
foot-baths. In ca.ses where the digestion is markedly feeble, the use of 
vegetable tonics is indicated. 

By far the most importiint part of the treatment, however, is a strict 
attention to the hygienic conditions of the patient. He should, so far as 
may be practicable, avoid all excitement and active exertion ; his diet should 
be digestible and nutritious, his clothing should be warm, and, in addition, 
be should carefully avoid all exposure to severe cold. 



284 DISEASES OF THE HEART. 

In cases where the venous congestion of the legs is marked and attended 
with oedema or with enlargement of the veins, laced stockings should be 
worn. 

It occasionally happens that cyanotic patients find that certain positions 
afford them peculiar ease and comfort. Believing that in cases where the 
lividity appeared soon after birth (cyanosis neonatorum), it was due to a 
patulous condition of the foramen ovale, the late Dr. Charles D. Meigs 
was led to recommend (Diseases of Children, 1850, p. 92), that such chil- 
dren should be placed upon a pillow, on the right side, the head and trunk 
being inclined upwards about 30° or 45°. The object of this position was 
"to bring the septum of the auricles into a horizontal position, so that the 
blood in the left auricle might press the valve of Botalli down upon the 
foramen ovale." 

In a certain number of cases the adoption of this recommendation has 
undoubtedly seemed to relieve the lividity, so that it is perhaps desirable 
that all cyanotic infants should be placed in this position ; though from a 
glance at the anomalies in the formation of the heart which frequently 
attend cyanosis, it is evident that in most cases it could furnish no material 
relief. We are ourselves inclined to attribute the relief afforded by this 
position, not to any influence upon the foramen ovale, but to the fact that 
the heart's action is far most free and unincumbered when the child is 
placed upon the right side, with the trunk somewhat elevated. 



ARTICLE II. 



DISEASES OF THE HEART. 



As we are prevented, by the limits of this work, from giving any detailed 
account of many of the affections which merely occur in childhood in com- 
mon with adult life, we propose in this article to offer only a few practical 
remarks upon the differences presented by diseases of the heart occurring 
at these two periods of life. 

Apart from those congenital malformations of the heart, already dis- 
cussed in the preceding article, the diseases of this organ most frequently 
met with in childhood, are pericarditis, and acute and chronic endocarditis, 
with valvular disease. 

The most frequent causes of these affections are rheumatism, the peculiar 
alterations of the blood present in scarlatina, rubeola, and diphtheria, and 
extension of inflammation from the adjacent tissues, in cases of pleurisy or 
pneumonia. Of these well-recognized causes, rheumatism is by far the 
most frequent ; for, although young children are comparatively rarely the 
subjects of this disease, it is followed by some cardiac complication in a 
larger proportion of cases in childhood than in after years. This fact will 
be more fully referred to in our remarks upon rheumatism, where we dwell 



ACUTE PERICARDITIS. 285 

upon the importance of recognizing this marked tendency, and of watching 
most critically for the appearance of any symptom indicating that the 
heart has become involved. This extreme watchfulness is the more neces- 
sary, because it frequently happens in young children, that for several 
days before the development of any local articular trouble, there may exist 
marked rheumatic fever, with serious inflammation of the membranes of the 
heart. 

In a few instances an acute cardiac aftectiou cannot be traced to any of 
the causes above-mentioned, but appears to occur idiopathically, without 
exposure to any recognizable exciting cause. 

So, too, in some cases of chronic valvular disease, and especially, it has 
seemed to us, of contraction and thickening of the mitral valve, the lesion 
cannot even be traced to any acute attack of endocarditis, but seems more 
akin to a fibroid degeneration, whose cause and early symptoms have been 
obscure and entirely overlooked. 

Possibly, in some of these interesting cases, the real starting-point of the 
disease may have been an attack of endocarditis in foetal life, which par- 
tially spoiled the valve, and set on foot degenerative changes, which slowly 
increased until they produced fatal symptoms. 

Acute Pericarditis may occur at any period after birth. In very 
young infants it has been observed in conjunction with peritonitis, and 
was apparently due to erysipelas; while in other cases no cause could be 
asisigned for its occurrence. The symptoms are, however, so vague and 
difficult to appreciate at this tender age, that the lesion is rarely recognized 
until after death. The infant is evidently in pain ; the features are pinched 
and shrunken, the skin hot at first, and the pulse and respiration greatly 
accelerated. The physical signs can, however, rarely be satisfactorily de- 
termined, partly because death usually occurs before the lesions reach any 
considerable degree of development. 

In older children the physical signs are often obscured by the coex- 
istence of some inflammatory condition of the lungs or pleura, and the 
existence of pericarditis can only be surmised by the presence of a degree 
of disturbance of the circulation and respiration out of all proportion to 
the amount of lung trouble. 

When, however, pericarditis occurs without any such complication, it 
may be often recognized by the seat of pain ; the existence of great dysp- 
noea, amounting at times to orthopna»a; the great frequency of the pulse, 
which is often small, and even irregular; the disturbance of circulation, 
as shown by lividity of the lips and face; and, finally, by auscultation 
and percussion, which reveal at first merely a friction-sound, and later, 
when eflTusion has occurred, distant and feeble heart-sounds, with an in- 
creased area of cardiac dulness. 

When severe, pericarditis in children usually proves fatal. After death 
the same anatomical lesions are found as after pericarditis in adult life. 
The membrane is, in the first stage, reddened, injected, dr}'ish, and slightly 
roughened ; while later it is still injected and even ecchymowd, thirkened, 
softened, and covered with patches or uniform layers of whitish or yellow- 
ish-white lymph, the surfaces of which are usually flocculeut or irregularly 



286 DISEASES OF THE HEART. 

roughened. The pericardial sac contains a variable quantity of turbid, or, 
at times, bloody serum ; or, in secondary cases, a sero-purulent fluid. 

In cases where recovery takes place, the results of the previous inflam- 
mation are found, after death has occurred from some other cause, in the 
form of more or less extensive adhesion of the two layers of the pericar- 
dium, or merely of thickening and opacity of that membrane. 

Treatment. — In idiopathic cases, if the disease be recognized in the 
early stage, we should advise local depletion over the prsecordia by three 
or four leeches or cut-cups in a child of Ave years of age, followed by the 
application of warm mush-poultices, the depletion being repeated if indi- 
cated ; the internal use of large doses of acetate of potash and iodide of 
potassium, associated with doses of veratrum viride of appropriate strength, 
to quiet the excessive vascular excitement ; and the careful administration 
of nutritious diet and small amounts of stimulus, if the powers of the cir- 
culation seem likely to yield to the influence of the disease. 

In the very rare instances where the disease becomes chronic, and the 
effusion remains unabsorbed, the treatment should consist in the repeated 
application of small blisters over the prsecordia, and the internal use of 
iodide of potassium, iodide of iron, with tonics and nutritious diet. In 
still more rare cases, the effect of chronic pericarditis is to induce ex- 
tremely thick layers of lymph enveloping the heart. In one instance 
which we lately saw in consultation with Dr. C. H. Thomas^ where pericar- 
ditis of several years' duration existed, the sac was obliterated by a layer 
of succulent almost gelatinous lymph fully one-half inch in thickness. 
In such a case, it is difficult to distinguish the lesion from hypertrophy of 
the heart. It might be done, however, by the absence of valvular mur- 
mur, and the feebleness of the apex-beat and of the heart-sounds. If, 
moreover, we have observed or can get an accurate account of the original 
attack, its character and the future course of the case would be of great 
value. 

Endocarditis. — In many cases, acute endocarditis in children occurs 
in conjunction with pericarditis, although it also occurs frequently as an 
independent aflfection. It is due to the same series of causes, also, as have 
been already enumerated when speaking of this latter disease ; of these 
undoubtedly rheumatism is far the most frequent. And as it is of far more 
frequent occurrence than pericarditis, and productive of even more serious 
results, it is necessary that we should, if possible, be more upon the alert 
to detect the very earliest symptoms of its presence. Since recent obser- 
vation has established the occurrence of acute afl^ections of the heart in 
the course of some other specific diseases, as stated in our remarks on peri- 
carditis, it is an important rule to use the same care in repeatedly examin- 
ing the heart in these cases also. 

In severe cases, whether occurring idiopathically, or as a complication 
or sequel of some other disease, there is violent disturbance of the circula- 
tion, with great dyspnoea, and short, dry cough, without any of the physi- 

^ See report in Transactions of Philadelphia Pathological Society, vol. vi, 
1876-77. 



ENDOCARDITIS. 287 

cal signs of pulmonary disea:?e. The child is extremely restless, and, upon 
ausoultation, an abnormal bruit is heard attending the heart's action. 
The valvular murmur, it must be remembered, is not harsh and strong as 
in some cases of chronic valvular disease, but may be so gentle and soft 
as to be heard with difficulty. 

In most eases, the mitral valve is chiefly atiected in acute endocarditis, 
and the murmur detected on auscultation is heard over the body of the 
heart and to the let\ of this organ, and often has its seat of greatest inten- 
sity near the apex. We have most frequently observed the murmur to be 
syst'^lic in time, attending and more or less obscuring the fii*st sound of 
the heart, in such acute cases. Of course, this indicates the existence of 
some imperfection in the closure of the mitral valves, allowing more or 
less regurgitation of blood into the auricle with each contraction of the 
ventricle. Occasionally a double murmur, attending both the systole and 
diastole, and indicating roughness as well as insufficiency of the mitral 
valve is heard. In more rare instances, we have found the aortic valves 
to be the seat of acute endocarditis, as shown by the presence of a single or 
double bhiwing murmur over the base of the heart, and transmitted most 
strongly upwards over the upper part of the sternum to the second right 
costal cartilage. 

But more frequently the acute symptoms are not so marked or charac- 
teristic as this, and, when ensuing, for instance, in the course of acute rheu- 
matism, may consist merely in a little increase of the heat of the skin, 
frequency of the pulse and restlessness, with or without vague complaints 
of pain about the praecordia. 

Absolutely the only way of recognizing such cases is by auscultation, 
and consequently we would urge the immense importance of carefully aus- 
culting the heart daily, not only in every case of acute rheumatism in a 
child, but also in every case where anomalous febrile symptoms, with ac- 
celeration of pulse, are present, and particularly if there be general sore- 
ness, or even resistance to motion. 

In very severe attacks of acute endocarditis, death may occur early ; 
but more commonly the disease is less severe, and the urgent symptoms 
subside, leaving, however, in but too many cases, organic valvular disease. 

When death occurs during the acute stage, the endocardium is i\m\u\ 
injected, reddened, softened, and readily detached from the muscular wall. 
The lesions are most marked on the left side of the heart, and esi)ecially 
on the endocardium covering the mitral valve, where, in addition to the 
above-mentioned appearance", there are usually patches or rows of minute 
granular vegetations, which form a fine beaded line along the free border 
of the valves; or, in other cases, delicate fringe-like processes which hang 
from the leaflets. We have alluded at some length in our article on 
chorea, to the theor}- which has been framed to explain the fre(|Uont oc- 
currence of this latter di.«ease in connection with rheumatism, by the sepa- 
ration of minute fragment** of such vegetations, and their impaction in 
some of the vessels of the brain. 

The treatment of acute endocarditis should be the same as that recom- 
mended for acute pericarditis. 



288 DISEASES OF THE HEART. 



CHRONIC VALVULAR DISEASES. 

There are certain general remarks which we desire to make in connec- 
tion with these affections, which are applicable to them, without reference 
to the particular valve diseased : in addition to which, we will call atten- 
tion to the diagnostic signs and special features of the diseases of each set 
of valves. 

Causes; Frequency. — In very many cases, heart disease in young 
children is recognized for the first time when such marked lesions exist 
as to convince us that the disease has already been of some considerable 
duration. Undoubtedly this is partly because the acute symptoms of the 
early stage have been entirely overlooked. This is particularly the case 
when the disease is rheumatic in its origin. We are convinced that acute 
rheumatism is often overlooked in young children, and also that endocar- 
ditis occurring in the course of such attacks not rarely escapes detection. 
It is, therefore, very difficult to say in what proportion of cases in young 
children, valvular diseases have been of acute origin. In our own experi- 
ence they have, with the exception of contraction of the mitral valve, 
almost universally followed an attack of endocarditis. In the case of mi- 
tral contraction, however, it is quite often impossible to trace the disease 
to any acute attack. It would appear, therefore, either that, contrary to 
the usual rule in early life, this lesion is often the result of a slow degene- 
rative, fibroid change, or else that, in some cases, it may arise in foetal life. 
This latter view does not seem at all impossible when we remember how 
slow is the development of this lesion, and for how long a time it may 
remain latent. 

As to the relative frequency with which the diflferent sets of valves are 
aflfected, lesions of the mitral valve undoubtedly preponderate largely. 
We have, it is true, met with extreme aortic disease in quite young chil- 
dren, marked by all the physical signs that are familiar as occurring in 
the adult ; but such cases have been rare compared to those in which the 
mitral valve was the seat of the disease. 

Anatomical Appearances. — The lesions which are found in chronic 
valvular diseases do not differ from those which are found in the adult, 
nor are they materially dependent upon the mode of their origin. It is, 
however, probably true that in those cases which have followed acute en- 
docarditis, it is more usual to find numerous and large vegetations upon 
the valves, than where the lesion has been chronic and of gradual devel- 
opment from the start. The lesions which are found usually, are vegeta- 
tions or calcareous incrustations on the valves, or there may be thickening, 
contraction, and coalescence of the valves and their chordae tendinese, 
either of which conditions may be attended with contraction of the orifices 
of the heart, and obstruction to the passage of blood. On the other hand, 
the contraction of the valves may be in such a direction as to render them 
insufficient to close the orifice, and thus allow regurgitation. The effect of 
these lesions upon the walls and cavities of the heart will vary with their 
degree and suddenness of development. Usually they are followed by 
dilatation of the cavities involved, and by thickening or hypertrophy of 



f 



DISEASES OF THE AORTIC VALVES. 289 

their walls, which has usually seemed to us more constant and to boar a 
larger proportion to the dilatation than in adults. 

Symttoms. — The general symptoms during the early stages of chronic 
valvular disease, are often extremely slight, consisting merely of some 
interference with the general development of the body ; a little palpita- 
tion of the heart, and dyspno?a on exertion ; occasional precordial distress, 
and j>erhaps slight prominence of the cardiac region. 

The vague character of these symptoms accounts for the fi\ct that, after 
the subsidence of the acute symptoms of endocarditis, when the disease 
has begun in that way, such cases are very often neglected, and receive 
no proi>er care until the occurrence of dyspnoea, cough, and dropsy, gives 
warning only in time to recognize the approach of the fatal termination. 

We make these remarks especially to call attention to the insidious mode 
of approach of many case^ of chronic valvular disease of the heart in 
children ; and to impress upon our readers the important practical rule 
that, whenever, in the investigation of a child suffering with obscure ill 
health, we learn of the previous occurrence of acute rheumatism, or find 
mentioned among the symptoms any irregularities of the circulation or 
action of the heart, careful physical exploration of the heart should im- 
mediately be practiced. 

The special symptoms which attend the diseases of the different valves, 
may be briefly described as follows : 

DUeases of the Aortic Valves. — These affections are, as already said, 
comparatively rare in children. The blowing murmur which attends 
them is usually strong and distinct. If the lesion causes obstruction of 
the aortic orifice, the murmur will attend the first sound ; if there be re- 
gurgitation through the valve, it will attend or take the place of the 
second sound. In many cases the lesion causes both obstruction and in- 
sufficiency, and there is therefore a double murmur. In either case the 
murmur will be heard extending from the base of the heart upward and 
across the sternum to the second right costal cartilage, as well as down- 
ward along that bone to the xiphoid cartilage. It is also transmitted into 
the arteries. The murmur is often so loud that, especially in cases of re- 
gurgitation, it may be heard down over the body of the heart to the apex ; 
and also to a varying distance on either side of the sternum over the upper 
part of the chest. Occasionally also a thrill may be felt over the upper 
piece of the .sternum, in the second intercostiil space at either the right or 
left edge of the sternum, or at the supra-sternal notch. 

The action of the heart is regular, and may not be accelerated, though 
exertion readily excites palpitation. The apex-beat is quick and strong, 
and is found after a time below and to the left of ita normal |K)sition. 
The area of cardiac percussion-dulne»s also becomes mo<lerately increased, 
in conse<juence of gradual hy[K,'rtro|>hy of the walls of the left ventricle. 

The pulse is small, quick, and in ca»e» of regurgitation, jerking and un- 
gustained, or receding. 

Id severe cases, there are marked evidences of interference with the ar- 
terial circulation. The surface i.<< pale, and shows the insufficient amount 
of blood which passes through the arterial capillaries. 

19 



290 DISEASES OF THE HEART. 

The respiration is usually but little disturbed, excepting in consequence 
of unusual exertion, so long as the lesion is limited to the aortic valve, and 
the walls of the left ventricle undergo sufficient compensatory hypertrophy 
to overcome the obstruction to the circulation. 

The prognosis in aortic disease of moderate severity has not seemed to 
us unfavorable so far as regards prolongation of life. Thus, for example, 
we treated a girl of 9J years, who had a violent attack of acute articular 
rheumatism with endocarditis. This was followed by a double aortic mur- 
mur, which persists to the present time, although she has grown up, mar- 
ried, and has one child. Her health is delicate, and she has very moderate 
dyspnoea on exertion. We have frequently observed this same tolerance 
of serious aortic lesions for a number of years. We have never met with 
a case in which sudden death occurred in the course of aortic regurgita- 
tion, as so frequently happens in adults. 

Mitral Obstruction. — This interesting form of cardiac lesion would merit 
a more full description here than any other valvular disease, because its 
symptoms are somewhat peculiar, and more especially because it is of such 
comparative frequency in childhood. 

Its origin, as we have already remarked, is usually insidious, and it is 
frequently impossible to gain any history of acute disease in cases where 
marked mitral obstruction is detected. 

The general symptoms which first attract attention to the heart are 
rarely noticed before the age of 7 or 10 years ; and we may then learn 
that during previous years the child has seemed as active and playful as 
usual, or that he has always shown an indisposition to active play or ex- 
ertion, and has become tired readily. Attention is attracted to the heart 
by the increased tendency to dyspnoea and palpitation on exertion, and 
by the readiness with which cough of a bronchial character is contracted 
on very slight exposure. Occasionally during these attacks of bronchitis 
with pulmonary congestion, haemoptysis may have occurred. Examina- 
tion may now show the existence of prominence of the prsecordia ; and 
the area of cardiac dulness is usually increased, though not to a marked 
extent. Frequently a thrill can be felt over the prsecordia, and careful 
examination will show it to occur just before the apex-beat. We have 
known this thrill to begin distinctly about the base of the heart, and to 
extend quickly down towards the apex, terminating as the apex-beat was 
noticed. On auscultation, a murmur, usually of a low, hoarse, or churn- 
ing character, is heard, which presents these additional peculiarities : it is 
generally distinctly presystolic or auriculo-systolic in time, occurring, that 
is. in the long period of silence preceding the first sound ; its relation to 
the phenomena of the cardiac action can usually be determined without 
difficulty by observing that it follows the second sound, and that it stops 
just before, or else runs into, the time of the first sound and the pulse of 
the carotid artery. This murmur, also, although usually quite strong, is, 
as a rule, remarkably localized in comparison to other valvular murmurs : 
its seat of greatest intensity is at or near the apex, and it loses force rap- 
idly on leaving this point in any direction. Attention to the peculiar 



MITRAL REGURGITATION. 291 

physical signs above given, as well as to the general symptoms, will gener- 
ally render the diagnosis clear. 

The prognosis, as regards prolongation of lite and maintenance of com- 
fort, is comparatively favorable ; as regards improvement in the organic 
condition of the heart, it is of conrse entirely the reverse. AVe have nnder 
our care at })resent a lad of 16 years of age who presents the typical symp- 
toms of mitral obstruction, but who, by care in his manner of living, enjoys 
entire comfort. Usually, however, the frequent recurrence of pulmonary 
congestion injures more and more seriously the equilibrium of the heart's 
circulation and the efficiency of the right ventricle, and eventually grave 
symptoms of failure of cardiac power, with general venous stasis, appear, 
and increase until a fatal result occurs. 

Mitral Beffiirffitntiou. — This, which is the most frequent form of cardiac 
disease in young children, depends upon inflammatory alterations in the 
mitral valve, which render it insufficient to close that orifice during the 
systole of the left ventricle. In most cases it arises from an acute endo- 
carditis, chiefly of rheumatic nature. In this condition, as in the last, the 
pulmonary circulation is apt to be disturbed from time to time, and there- 
fore the early general symptoms which attract attention to the thoracic 
organs are usually shortness of breath on exertion, liability to cough, and 
palpitation of the heart. Of course, where we are in attendance upon the 
case of rheumatism when the acute cardiac inflammation occurs, the fact 
will be recognized by the symptoms detailed under the head of acute en- 
docarditis. But unfortunately it often happens that this acute stage is 
quite overlooked, and we would therefore again urge the importance of a 
careful physical examination of the heart in every case where a child is 
brought to us complaining of vague symptoms of embarrassed breathing, 
though no suspicion has ever been raised of the existence of heart disease. 
Sometimes, indeed, much more marked general symptoms will have ap- 
peared, as, for example, severe dyspnoea on exertion, pulmonary congestion 
with cough and moist or dry rales over the posterior parts of the lungs, 
palpitation of the heart, lividity of the lips and fingers, and even oedema 
of the feet. 

On physical exploration we often find prominence of the pnecordia, with 
signs of more considerable hyi^ertrophy and dilatation than in cases of 
mitral obstruction. The impulse is extended and too forcible, or may even 
be heaving; it is rarely attended with any thrill. On auscultation a blow- 
ing murmur, which varies very greatly in different cases in its force and 
character, will be heard accompanying or replacing the first sound of the 
heart. This murmur is heard at the base, and is transmitted most strongly 
towards the apex, where it often has its point of greatest intensity. It is 
also strongly transmitted to the left of the apex, being well heard in the 
infra-axillary space on the level of the a|K^x-beat, and fre(juently, also, on 
the dorsum of the left chest, at the angle of the scapula. The only other 
form of valvular disease with which it is possible to confound this is mitral 
obstruction ; but attention to the evident points of difference noted above 
will render the diagnosis easy in most cases. 

The prognosis varies extremely in different cases, def>endiug upon the 



292 DISEASES OF THE HEART. 

extent and rapidity of development of the lesion ; the completeness with 
which the disturbance of the circulation is compensated by the hypertrophy 
and increased power of the walls of the left ventricle ; and the vigor of the 
system and the preservation of the tone and nutrition of the muscular fibre 
of the heart. This form of heart disease illustrates more clearly than any 
other the more favorable prognosis which may be made in many cases of 
organic valvular disease in children, as compared with the same condition 
in adults. This depends partly upon the fact that when the lesion is not 
extensive, and when the patient is placed under favorable circumstances, 
the heart accommodates itself in its growth to the defective state of the 
valves, and overcomes the impendiment to the circulation by acquiring in- 
creased propulsive force. 

Not only, however, are the valvular lesions in childhood thus partly 
compensated by hypertrophy of the walls of the heart, but there is also an 
undoubted tendency, in some favorable cases, for the valvular lesions, both 
mitral and aortic, themselves to diminish. Thus among the following 
cases, which we have selected from a large number of records collected in 
our practice, there will be found several where positive abnormal bruits, 
due to organic valvular disease, have gradually disappeared in the course 
of years. 

Acute articular rheumatism ; endocarditis ; recovery ; murmur persistent hut di- 
viinishing. — H. S., a boy, set. 12 years, had a severe attack of acute articular rheu- 
matism in April, 1869, with swelling, redness, and pain of joints ; a systolic murmur 
appeared at the apex without any pericarditis. He recovered, under the use of 
alkalies and opium. In November, 1869, seven months after the attack, he seemed 
perfectly well; had no dyspnoea except on violent exertion. The murmur at the 
apex is still audible, but less marked than three months ago, when he was last 
examined. 

Acute endocarditis (rhewnatic?) ; fnarked imp7^ovement in general symptoms, but 
persiste7U mia^tnur — B. H., a girl, at age of 4 years suffered from an ordinary ca- 
tarrh, when we detected a loud, high-pitched murmur at the apex, and, on inquiry, 
learned that, when 2^ years old, she had a violent inflammation of the chest, sup- 
posed to be catarrhal fever. At present, at the age of 12 years, she is in excellent 
health, without any of the rational signs of cardiac trouble, but she still has a 
well-mai'ked, rather prolonged, high-pitched, systolic murmur at the apex. 

Repeated attacks of rheumatism with severe mitral disease; improvement in general 
symptoms and force of the m,urmur. — L. S., a girl, was subject to attacks of rheuma- 
tism from very early age, and has presented symptoms of cardiac disease from in- 
fancy. At age of 13, there was a strong systolic murmur heard over base and 
toward apex. She suffered much from violent palpitation, pain in prspcorditi, head- 
ache, and habitual dyspnoea, much increased on exertion. At age of 18, there is 
still a systolic mitral murmur, but of much less intensity than formerly. Her gen- 
eral health is excellent, and she has but little dyspnoea or palpitation at any time. 
The heart's action is still readily excited; the impulse strong, but without thrill; 
there is marked increase in the area of cardiac dulness, but no positive prominence 
of the praecordia. 

Acute rheumatic endocarditis, chr(mic mitral disease / recovery in five years. — F. R., 
a girl, at the ago of 6 years, was attacked with slight rheumatic fever, without any 
articular symptoms. In a few days, a distinct but not loud, rather low-pitched 
systolic murmur was heard at the apex. The treatment consisted of rest in bed, 
quinia, and Dover's powders. After ten days, all the acute symptoms disappeared, 
but the murmur continued. She regained her health, but for two years the mur- 



CASE. 293 

mur could be detected, but then ajradually diminished ; and now, five yenrs after 
first attack, no murmur can be detected, the first sound at the apex beinsj: merely a 
little prolonged. Her general health is excellent. 

Acute t'hrtimafie endocarditis ; valrnlar diicnse, (jradualb/ rccovcrin(^ in coio'se of 
two years. — M. B., a girl, at the age of 7 years had fever of a type that made us 
suspect pneumonia or pleurisy, but without cough, pain in the chest, or any of the 
physical signs of pulmonary disease. On the third day, there was coniplaint t)f 
pain in one groin, but with no other articular symptoms; rheumatism being sus- 
pected, a careful examination detected a roughish systolic murmur at the apex. 
She was leeched at the prax'ordia, confined strictly to bod, and had Dover's powders 
given her. The fever subsided, but the murmur continued for two years, gradu- 
ally growing faint, and finally disappeared. 

It is, however, only when the general nutrition of the patient is good, 
so that the tonicity of the heart's tissue is preserved ; and when all ex- 
p<isure and exertion, which could overtax the energies of the crippled 
organ, are carefully avoided, that such compensation and gradual recovery 
are possible. 

For in cases where the vigor of the heart's action fails, and degenerative 
changes occur in its muscular tissue, the tonicity of the walls soon dimin- 
ishes, and allows the development of passive dilatation of the cavities. In 
this condition it is not long before the most grave symptoms of embar- 
rassed circulation appear, and the case passes more or l«.?s rapidly through 
the stages common to fatal organic disease of the heart. 

The following case may be quoted as a full illustration of the latter 
remarks, in regard to the effect of exposure and exertion in inducing a fatal 
result in cases which otherwise might have gradually improved. 

Repeated attacks of acute rheumatism in early childhood ; valvular disease and 
hypertrophy ; ffradual improvement ; exposrwe to hardships of army life ; rapid aggra- 
vation of symptoms and death. — W. D., male, as a young child suffered from re- 
pealed attacks of acute articular rheumatism with cardiac complication. At the 
age of 9, Dr. Gerhard pronounced him to be suffering from valvular disease and 
hypertr<»phy of the heart. 

His condition was gradually improving, and he had so few symptoms of cardiac 
disease that, at the age of IS years, he was able to enter the infantry service. At the 
end of one year, however, he was discharged for disability, and whon seen by us 
in July, 1864, prespnted the following symptoms: bulging of pnccordia : marked 
extension of the cardiac impulse, which was heaving and powerful ; marked in- 
crease in the area of cardiac dulness from the presence of pericardial efl'usion ; and 
strong systolic mitral murmur. He had lost flesh ; the surface was sallow and lips 
livid ; there was frequent cough with occasional hemoptysis and epistaxis ; the 
liver was enlarged, and there was frequently oedema of the feet. 

Towards the close of the 3'ear, the heart's action grew more labored and feeble, 
the pulse thready and frequent, the entire body became anasHrcous, and consider- 
able ascites appeared. Ho suffered from constant orthopna?a and frequent cough, 
with bloody expectoration. The skin of the legs subsequently be<ame gangr«'n<»us 
in part«, and he died December 28th. 

At the autopsy, the h^art was found enormously enlarged, extending r)ver to the 
right of the sternum. The pericardium wa** firmly adherent throughout its extent, 
and in places was \ inch thick ; there were several cartilaginoid plates in the sub- 
stance of the inveifting pericardium. 



294 DISEASES OP THE HEART. 

The heart measured 9h inches from apex to base, and 6 inches across at the base 
of the ventricles ; the walls of the left ventricle were 1^ inches thick ; the auricles 
were enormously dilated with very thin walls. The aortic and pulmonary valves 
were healthy and apparently sufficient; the tricuspid valves were also healthy, but 
probably insufficient. The mitral valves had entirely disappeared, from shrivelling 
and contraction, and there merely remained a very thick fibrous ring, studded with 
calcareous masses, bounding the auriculo-ventricular opening. 

The muscular tissue of the heart presented an incipient state of fatty degenera- 
tion. 

The liver was enormously enlarged, reaching nearly to the umbilicus, and pre- 
sented intense nutmeg congestion. 

The kidneys were large and congested ; and the spleen was three times its normal 
size. 

Treatment. — Having spoken somewhat in detail of the symptoms and 
prognosis of the different forms of valvular disease in children, it remains 
to make some general remarks upon their treatment. In the management 
of such cases, as in adult life, the most important point to be attended to 
is the careful regulation of the mode of life. The child should be warmly 
clothed, and carefully protected from any exposure which might induce 
an attack of rheumatism ; all violent exertion of body or mind should 
also be avoided, and, so far as possible, all sudden emotions, as fright or 
anger. On the other hand, care should be taken that proper gymnastic 
and outdoor exercise should be regularly taken in such ways as to invig- 
orate the frame and strengthen the muscular system, without producing 
too mucl^ exhaustion. The diet should be nutritious and digestible, and 
if the appetite should fail, and the child appear weakly and pale, vegetable 
tonics, with iron, should be administered. 

The appearance of symptoms of pulmonary congestion, or of catarrh, 
should attract immediate attention, and lead us to employ counter-irrita- 
tion and suitable expectorants to relieve the lungs. 

In cases where the heart's action is excited, and too frequent and power- 
ful, while evidences of excessive hypertrophy begin to show themselves, we 
should employ cautiously veratrum viride or aconite to control it. When, 
on the other hand, any of the cavities of the heart are subjected to over- 
strain from valvular obstruction or insufficiency, and the heart is acting 
irregularly and inefficiently, the greatest benefit will be obtained from 
the use of digitalis. Indeed, in many instances we have observed, under 
the prolonged use of this drug, very great permanent improvement, grad- 
ually showing itself both in the action of the heart and in the general 
symptoms. 

Severe paroxysms of palpitation, should they occur, require the use of 
antispasmodics, diffusible stimuli, and revulsives, just as are indicated 
under the same circumstances in the adult. Should the attack not sub- 
side promptly, recourse should be had to digitalis, which may be freely 
administered, and will be found to afford marked relief. 

In cases of rheumatic origin especially, we have thought that good 
results, in regard to the progress of the organic changes in the heart, have 
followed the prolonged use of iodide and bromide of potassium, given 



TREATMENT. 295 

with due regard to the danger of developing an anaimic state of tlio blood 
by the uninterrupted administration of these drugs for a long time. 

On the whole, as we have already said, there is reason to be somewhat 
hoj^eful in the treatment of chronie valvular disease of moderate severity 
in young ehildren, bearing in mind the wonderful power whieh the grow- 
ing heart possesses of compensating such lesions, so long as by careful 
attenti«>n to hygiene and medical treatment we are able to preserve the 
tone and nutrition of its muscular tissue. 



CLASS III. 

DISEASES OF THE DIGESTIVE OKGANS. 
CHAPTEE I. 

DISEASES OF THE MOUTH AND THROAT. 

"We have adhered to the arrangement of this subject adopted in our last 
edition, and shall consider the diseases of the mouth in the following order : 

1. Simple or erythematous stomatitis. 

2. Follicular stomatitis, or aphthae. 

3. Ulcerative, or ulcero-membranous stomatitis. 

4. Gangrene of the mouth. 

5. Thrush, or stomatitis with curd-like exudation. 

6. Affections of the tonsils. 

7. Simple, or erythematous pharyngitis. 

8. Retropharyngeal abscess. 

In the early editions of this work, we described pseudo-membranous 
pharyngitis in this place, but further observation and research have clearly 
established the fact that this is but the local manifestation of a constitu- 
tional affection, diphtheria ; and we have accordingly given a full account 
of the whole subject, under this latter name, in the section on constitutional 
diseases. 



ARTICLE I. 



SIMPLE OR ERYTHEMATOUS STOMATITIS. 

Definition ; Frequency. — This form of stomatitis consists of simple 
diffuse inflammation of the mucous membrane of the mouth, unattended 
by vesicular or pustular productions, by ulcerations, or by membranous 
exudation. It is a disease of infrequent occurrence, except in the forming 
stage of other kinds of stomatitis, and of little importance, seldom requir- 
ing the attention of the physician. 

The causes of the disease are the introduction of irritating substances, 



APHTHA. 297 

such as hot drinks, and acrid or caustic preparations, into the mouth ; diffi- 
cult dentition ; and probahly sympathy with disordered states of the stom- 
ach. It occurs not uufrequently as a secondary aHection, particularly in 
the course of measles, scarlet fever, and small-pox. 

The ^yviptoim of erythematous stomatitis are more or less vivid redness 
of the mucous membrane, sometimes diflused, and at others punctated or 
disposed in patches; slight swelling of the same tissue; heat; and tender- 
ness to the touch, and also in the act of sucking or eating. The child is 
generally fi-etful and restless, and either loses its appetite, or refuses to nurse 
or take food freely, on account of the tenderness of the mouth. There 
are seldom any general symptoms except in secondary cases, in which they 
are those of the primary affection. 

The treatment is very simple. It consists in the use of some demulcent 
wash, as gum water, sassafras-pith mucilage, a little honey put on the tongue 
occasionally, and if the intiamiuation be at all considerable, in the appli- 
cation of some astringent preparation. This may consist of honey and 
borax, two or three parts of the former to one of the latter, or of the fol- 
lowing wash, recommended by M. Bouchut : 

R.— Mel. Rosa-, f5J. 

Aluminis, ^ss. 

Aqu» destillat., ^oss. — M. 

The application of any of the washes recommended is best made by 
means of a thick and soft camel's-hair pencil ; or it may be done with a 
soft rag, which should be dipped in the wash, and then conveyed into the 
mouth on the point of the finger. The remedy ought to be used several 
times a day. 

If signs of gastric or intestinal disorder are present, they should be 
attended to. 



ARTICLE II. 

APHTHiE. 



DEFixmoN; Syxoxyms; Frequency; Forms. — The term aphtha^ 
ought to be restricted to the vesicular and ulcerous form of disease of the 
buccal mucous membrane, in which that tissue is covered with an eruption 
of vesicles which break, and are followed by small rounded ulcerations. 
Under thi.s title writers formerly confounded the affection we are now con- 
.«idering with ulcerative stomatitis and thrush. It has been called by 
Billard follicular stomatitif?, and by several other writers vesicular stoma- 
titis. 

The freqtieney of the disease is very considerable. We shall describe 
two/omi>r, the discrete and confluent. 

Cal«i><. — The only causes which seem to have been ascertained with 



298 APHTHJ3. 

any degree of certainty, are early age and the process of dentition : the 
contact of irritating substances, particularly stimulating and acrid articles 
of food, with the raucous raembrane of the mouth ; and the existence of 
some morbid irritation of the digestive tube, especially of the stomach. 
The confluent form is often connected with severe general disease of the 
constitution. 

Symptoms ; Duration. — Aphthae begin in the form of small red eleva- 
tions, having little white points upon their centres, which consist of the 
epithelium of the mucous membrane raised into vesicles. The vesicles 
are small in size, oval or roundish in shape, and of a white or pearl color. 
They soon break and allow the fluid which they contained to escape, after 
which there remains a little rounded ulcer, with excavated and more or 
less thickened edges, and surrounded almost always by a red circle of in- 
flammation. The bottom of the ulcers is usually of a grayish color,^ There 
is seldom any diffuse inflammation of the mucous membrane in this dis- 
ease. The number of aphthse varies in the two forms. In the discrete 
variety there are but few, whilst in the confluent form they are, of course, 
much more numerous. They generally appear first on the internal sur- 
faces of the lips and gums, and then on the inside of the cheeks, edges of 
the tongue, and soft palate. 

The discrete form is generally accompanied by symptoms of slight dis- 
order of the digestive organs, consisting of thirst, acid eructations or vomit- 
ing, imperfect digestion, and a little constipation or diarrhoea. The con- 
fluent form, which is much more rare, especially in very young infants, 
usually coincides, as has already been stated, with severe general or local 
disease. 

The duration of aphthae is different in the two varieties of the affection. 
The discrete form generally pursues a rapid course, lasting from the begin- 
ning to the time of cicatrization, between four and seven days. Some- 
times, however, when the vesicles are formed successively, one after the 
other, the disease lasts much longer. The confluent variety pursues a 
much slower course, and is much more difficult of cure. 

Diagnosis and Prognosis. — The diagnosis of discrete aphthae is not 
at all difficult, in consequence of their being isolated and succeeded by 
small and limited ulcerations. The confluent form, on the contrary, may 
be confounded with ulcerative or ulcero-membranous stomatitis, and with 
thrush. From the first-mentioned disease it may be distinguished, however, 
by attention to the circumstances that that affection begins by small white 
patches, and not by vesicles, as do aphthae ; that the ulcerations which fol- 
low the patches are covered with true pseudo-membrane; and that the 
white patches just spoken of appear first upon the gums, whilst aphthae 
generally begin upon the posterior surface of the inferior lip, and upon the 

^ The grayish or yellowish-gray secretion, on the base of the aphthous ulcers, 
has lately been closely studied by Dr. J. Worms (Glasgow Med. Jour., July, 1864), 
who states that both microscopical examination and chemical tests invariably show 
its sebaceous nature. It is his opinion, therefore, that aphthae are the acne of the 
mucous membranes; in support of which, it will be remembered, that they are 
found most frequently where the muciparous glands are most abundant. 



GENERAL TREATMENT. 299 

tongue. From thrush it is to be distinguished by the facts that that dis- 
ease commences by white points, which are not vesicuhir, and which, run- 
ning together, form a creamy exudation ; by the absence or very small 
number of ulcerations; and by the presence of the peculiar fungus of 
thrush. 

Discrete aphtha^ constitute a very mild disorder. They always recover 
without much ditticulty. The confluent disease is more serious, because 
its progress is much slower, its cure more difficult, and because it is often 
conn^ct<id, as has been stated, with some other severe disease. 

Trkatmknt. — Aphtha^ particularly the discrete variety, require in 
general, very simple treatment. The means to be employed are general 
and topical. 

The discrete variety usually requires only topical remedies, regulation of 
the diet, and when there are marked symptoms of gastric derangement, 
the exhibition of some mild emetic, or of a laxative dose. The local treat- 
ment should consist of applications of demulcent preparations, as the mu- 
cilages of slip|)ery elm, sassafras pith, flaxseed, mai-sh-mallow root, quince- 
seed, etc., which are to be used pure when there is no pain, or with the 
addition of a few drops of laudanum or wine of opium, when the mouth is 
sore and tender; the aphtha? ought to be touched occasionally with the 
mixture of borax and honey, or the aluminous preparation recommended 
for simple stomatitis. The applications must be made several times a day 
with a camel's-hair pencil, a pencil made of charpie or cotton, or with a 
soft rag covering the finger. When the ulcers which follow the vesicles 
fail to cicatrize rapidly under the above applications, or when they are 
numerous and painful, their cure may be very much hastened and the pain 
quickly relieved, by touching them very lightly with a stick of nitrate of 
silver, or a piece of alum, sharpened to a point ; or we may employ a pen- 
cil dipped into a strong solution of nitrate of silver, or into a mixture of 
one part of muriatic acid to two of honey, father has been highly recom- 
mended as a local application, by Dr. J. Worms, who, as already stated, 
has observed the fatty nature of the deposit in aphthous ulcers. 

The general treatment of discrete aphthic need consist of nothing more 
than the prescription of a simple, unirritating diet in most of the cases. 
If, however, the digestive apparatus is deranged, the case must be treated 
according to the symptoms ; by antacids or a gentle emetic, when the 
tongue is foul and the secretions acid ; and by the use of a mild laxative, 
as castor oil, magnesia, or rhubarb, when there h constipation. When 
diarrhrea is prei»ent, we should rc-ort first to a small dose of castor oil or 
syrup of rhubarb, with the ad<lition of half a drop to two drops of lauda- 
num, according to the age of the child, and afterwards to astringcnt^s and 
opiates, as will be recommended in the article on simple diarrh(ea. 

The treatment of confluent aphthte roust depend on their cause. The 
local treatment is the same as that for the discrete variety, except that 
mild cauterization should be resorted to at an earlier period. When they 
seem to depend upon a general morbid condition of the constitution, as 
congenital debility, a 8<.'orbutic diathfjsis, or up<^)n chronic affections of the 
digestive organs, they must be treated in the first place by properly rcgu- 



300 ULCERATIVE STOMATITIS. 

lated and nutritious diet, and by the exhibition of tonics and gentle stimu- 
lants, particularly iron, quinine, and small quantities of very fine old 
brandy ; and in the second case, in the manner which will be recom- 
mended for chronic derangements of the stomach and bowels, when we 
come to treat of the diseases of those organs. 



AKTICLE III. 



ULCERATIVE OR ULCERO-MEMBRANOUS STOMATITIS. 

Definition ; Synonyms ; Frequency. — This form of sore mouth is 
characterized by a secretion upon the inucous membrane of a plastic exu- 
dation in thick, yellowish, adherent patches, and by inflammation, erosion, 
or ulceration of the subjacent tissues. It is the same disease as the aphtha 
gangrenosa, and, we believe, the cancrum oris also of Underwood ; the ul- 
ceration of the mouth of Dewees and Eberle ; the stomatite couenneuse, 
and the ulcerative and pseudo-membranous forms of the stomatite gan- 
greneuse of M. Valleix; the stomatite pseudo-membraneuse or diph- 
theritique of some writers ; and the stomatite iilcero-membraneuse of 
MM. Rilliet and Barthez. It is the disease described under the title of 
gangrenous sore mouth by Dr. B. H. Coates (North American Surgical 
and Medical Journal, vol. ii, 1826), with the exception of a few cases 
which were what we shall treat of as gangrene of the mouth. 

Of the different titles given above, we prefer that of ulcero-membranous 
stomatitis, as most expressive of the distinctive features of the disease. 
This form of stomatitis is not very frequent in private practice, but some- 
times prevails extensively in hospitals, and other public institutions for 
children, where it often assumes an epidemic character. 

Causes. — The predisposing causes are epidemic influence, of the exist- 
ence of which we believe there is no doubt ; according to some observers, 
contagion, which, however, has not as yet been positively shown ; and bad 
hygienic conditions as to cleanliness, ventilation, food, clothing, and habi- 
tation. That it is epidemic, we have no doubt from our own experience, 
since we are rarely called to a case without soon meeting with others, while 
we sometimes pass several months without seeing a single example of the 
disease. We have also known it to be endemic in a household, having on 
one occasion met with seven cases in two families of children residing 
under one roof, on two other occasions with three cases, and on several 
others with two. It is most frequent between the ages of five and ten 
years, though it may attack all ages, and is more common in boys than 
girls. It occurs occasionally during the convalescence from severe dis- 
eases, as pneumonia, the eruptive fevers, typhoid fever, entero-colitis, and 
other affections of children. 

The exciting causes of sporadic cases are unknown, with the exception, 



SYMPTOMS — COURSE — DURATION. 301 

» 

perhaps, of the presence of a carious tooth in the month, and fracture or 
necn)sis of the maxiUary bones. 

Symptoms; Course; Dukatiox. — The disease begins with slight pain 
and uneasy sensations in the gums, which then become swelled, red, bleed- 
ing when touched, and are soon after covered with a grayish, pultaceons 
exudation of varying thickness. The exudation extends from the gums 
to the internal surface of the lips and cheeks, and sometimes, but more 
rarely, to the soft palate, and even to the pharynx and nasal passages. 
The plastic deposit occui-s in the form of small, and slightly projecting, 
yellowish j>atches, which approach each other, unite, and form bands of 
pseudo-meml)rane, somewhat uneven upon the surface, and adhering with 
considerable force to the tissue beneath. When the exudation is detached, 
the mucous membrane is found to be of a red or purple color, bleeding, 
and excoriated or ulcerated. The ulcerations which exist under the false 
membrane are of various depths, of a grayish, livid, or blackish color, 
with sA^elled, softened, and livid red, or bleeding edges. Those which are 
formed upon the inside of the lips are rounded in shape, whilst those seated 
in the angle between the lips and gums, are usually elongated. In mild 
cases of this affection, the local symptoms, though perfectly characteristic, 
are less severe than those just now described. The ulcerations are often 
few in number, amounting to four, five, or six upon the tongue, to a few 
scattered over the inner surfaces of the lips, and to some upon the gums, 
and esi>ecially about the necks of the teeth. The other symptoms are the 
same as those above mentioned, with the exception that they are milder in 
degree. 

When the disease is mild, and when it is properly treated, the false mem- 
branes become detached, leaving the mucous tissue merely excoriated, in 
which case it soon regains its natural condition ; or else the ulcers which 
exist beneath rapidly become healthy and cicatrize. In violent cases and 
in those badly treated, the infiammatiou, on the contrary, persists ; the 
pseudo-membranes increase in thickness, or if detached, are formed anew ; 
the ulcerations become deeper ; the disease extends ; and the case lasts an 
indefinite period of time. 

Other symptoms, besides those we have mentioned, characterize the dis- 
ease. 

The breath is always more or less fetid, and in bad cases, almost gan- 
grenous. The miliary and submaxillary glands are generally more or less 
swelled, hard, and painful, and according to some autiiors, the surrounding 
cellular tissue is in the same condition, though this is denied by others. 
The movements of the lower jaw are stiff and painful in severe cases. 
Def/lutition is not affected unless the disease extends to the pharynx. In 
violent ca.ses there is usually a copious diKchargfi of fetid, watery saliva, or 
of bloody serum, which flows from the mouth during sleep. When the ul- 
cerations are deep and large, the tissues beneath are more or less swelled ; 
the swelling, however, rarely assumes the hard, resisting, circumscribed 
characters, with the tense, smooth, hot, and shining appearance of the skin, 
which exists in true gangrene of the mouth. In most of the cases there is 
a moderate but decided febrile reaction, especially at the invasion. This 



802 ULCERATIVE STOMATITIS. 

usually subsides or disappears after two or three days, though it sometimes 
increases if the disease becomes extensive. 

The disease begins, as already stated, on the gums, and unless limited 
to these parts, as sometimes happens, extends to the lips and cheeks. In 
many of the cases it attacks only one side of the mouth, and this is more 
frequently the left than the right. 

The course of the disease is usually rapid in epidemic cases, and in 
those which are properly treated. Where badly treated, on the contrary, 
it may last from one to several months, or terminate in gangrene of the 
mouth. 

Diagnosis ; Prognosis. — The diagnosis is, as a general rule, very easy, 
if proper attention be paid to the characteristic features of the disease. 
It has, as already stated, been very often confounded with gangrene of 
the mouth. The method of distinguishing between the two will be given 
in full in the article on that disease. From thrush it is to be distinguished 
in the manner which will be pointed out when that disease comes under 
consideration. 

T\\Q prognosis is favorable in the great majority of the cases. Sporadic 
cases probably always terminate favorably. The epidemic disease, though 
rarely fatal, sometimes proves so from its extension to the pharynx and 
larynx, or from its termination in gangrene of the mouth. We have seen 
a large number of cases in private practice, and have never as yet known 
one to become gangrenous or to prove fatal. Of upw^ards of 120 cases 
of this kind, observed by Dr. Coates at the Philadelphia Children's Asy- 
lum, in a period of three months, all but one recovered {loc. ciL, p. 21). 
The cases which occur in the course of other diseases are not dangerous 
in themselves, but are so as being the sign of a great severity of the pri- 
mary affection. 

Treatment. — The treatment may be divided into general, and local or 
topical. The general treatment should consist in most of the cases in at- 
tention to the diet, which ought, in healthy and vigorous children, to be 
simple and unirritating, and in those who are weak and debilitated, nutri- 
tious and digestible. If the bowels are costive, or the child feverish and 
uncomfortable, a laxative dose may be given with advantage ; or some 
simple diaphoretic, as nitre and water, or the neutral mixture, may be 
used through the day, and a warm foot-bath or an immersion-bath given 
in the evening. When the constitution is feeble, and the child Aveak or 
ansemic, tonic remedies are indicated. The best is probably quinine, or 
one of the ferruginous preparations; or the compound infusion of gentian, 
with addition of Huxham's tincture of bark, may be resorted to. The 
best internal remedy, however, and indeed the only one of any kind that 
is necessary in most cases, is the chlorate of potash, which possesses a 
stimulant and alterative action upon the mucous membranes. This is 
spoken of in the highest terms by Dr. West, of London, who regards it 
almost as a specific. We have used it now for many years past in a very 
large number of cases, and have seldom found it necessary to employ any 
other means, excepting some mild cathartic dose where the bowels have 
been constipated, and a wash of borax or alum in honey of roses, or borax 



TREATMENT. 303 

in simple honey. The symptoms have begun to amend in every case in 
from three to four or five days, and recovery has taken place in about a 
week or a little more. The dose is from two to three grains every four 
hours for a child three years of age, and four and five grains for one of 
nine or ten years. Mr. Hutchinson {Med. Times and Gaz., 1856), who be- 
lieves also that this salt is almost a specific in this affection, recommends 
it in larger doses than the above, giving as much as five grains, thrice 
daily, to an infant of one year old. We have usually prescribed it in the 
dose of two grains four times a day, in a mixture of syrup of ginger and 
water, for children three or four years old. 

Prior to the discovery of the efficacy of the chlorate of potash in the 
afiection, the local treatment constituted the only effectual and reliable 
means of removing it, and the most violent and painful applications were 
thought necessary and were made use of. Strong solutions of nitrate of 
silver, and pure or diluted muriatic acid, were frequently employed in 
severe cases. Now, however, these caustic substances may probably be 
entirely dispensed with, except in cases that show a tendency to assume 
the form of gangrene of the mouth. In ordinary cases the only local ap- 
plications that need be used, and these are not essential when the child 
resists very much, are demulcent washes to keep the mouth clean, to be 
employed in the manner recommended in the article on aphtha?, and some 
mild astringent wash. This may consist of borax and honey, or borax 
and sugar, in the proportion of two or three parts of the former to one of 
the latter, or, what is in our opinion preferable to either of these, of a 
drachm of borax rubbed up with an ounce of honey of roses. 

Should the disease resist the treatment by the chlorate of potash and 
the simple washes just now recommended, we may employ the following 
combination, proposed by Dr. Dewees, and of which he says that it " has 
so far never failed us." 

R. — Sulph. Cupri, ...... gr. x. 

Pulv. Cinch. Opt., ..... ^ij. 

Pulv. G. Arab., 3J. 

Mel. Commun., i^]}. 

Aquae Font., f.^'O- — M. etftsol. 

The ulcerations to be touched with the mixture twice a day, with the 
point of a camel's-hair pencil. Or, we may resort to the following one rec- 
ommended by Dr. Coates (loc. ci7.), and of which he says, that he "settled 
down, after various trials, in the employment of the following: 

B.— Sulph. Cupn, 3ij. 

Pulv. Cinchona", ....... ^^^s. 

Aquse, ^.5'^. — M. 

To be applied twice a day, very carefully, to the full extent of the ulcera- 
tions and excoriations." 

MM. Killiet and Barthez recommended ver>' highly the plan pur^urd by 
M. Boneau at the Children's Hospital. This is to cleanse the mouth first, 



30: 



GANGRENE OF THE MOUTH. 



and then to apply dry chloride of lime (calx chlorinata of the Pharma- 
copceia) to the diseased surfaces. The application is made by means of a 
piece of rolled paper, or a stiff pencil, which is to be moistened and then 
dipped into the powder so that some may adhere, or with the finger. The 
surfaces are to be gently rubbed with the powder, and after a few moments' 
contact, w^ashed clean with pure water. This is to be done twice a day, 
until the ulcerations assume a clean, healthy appearance, after which the 
following mouth-wash is to be employed : 



R.— Mucil. Gr. Acac, 

Syrup. Cort. Aurant., . 
Calc. Chlorinat., . 



f^ss. 



The chief danger from the disease depends on the circumstance that it 
sometimes terminates in gangrene of the mouth, to be presently described. 
Any disposition to such a termination should be carefully watched, and the 
proper preventive means, consisting of local stimulating or caustic applica- 
tions, with the internal use of stimulants and tonics, be at once resorted to. 



AKTICLE IV. 



GANGRENE OP THE MOUTH. 



Definition ; Synonyms ; Frequency. — Gangrene of the mouth is an 
affection which occurs chiefly in children of debilitated constitution, and 
especially as a sequel of some of the eruptive fevers. It begins generally 
by ulceration of the mucous membrane of the cheek, which after a longer 
or shorter time, runs into gangrene, and extends rapidly to the gums ; 
after a few days, if the disease be not arrested, the central tissues of the 
cheek become thickened and indurated, an eschar forms upon the integu- 
ment, and spreads in depth and width, until at last the cheek may be per- 
forated, the whole side of the face and jaws destroyed, the teeth loosened, 
and the maxillary bones exposed and necrosed. It is known by a great 
variety of names: gangrsenopsis, cancrum oris, gangrsena oris, canker of the 
mouth, gangrenous erosix)n of the cheeks of Underwood ; necrosis infantilis, 
gangrenous stomatitis, etc. It is a frequent disease in the hospitals for 
children in Europe, and a not uncommon one in institutions of the same 
kind in this country. It sometimes prevails endemically in hospitals. It 
is a rare disease in private practice, and we have as yet met with but few 
cases, excepting in public institutions. 

Predisposing Causes. — The disease is nearly, but not exclusively con- 
fined to the period of childhood. It is most common between the ages of 
three and six years ; is very rare, but does sometimes occur in infants ; and 
is of nearly equal frequency, probably, in the two sexes. Unfavorable 
hygienic conditions constitute a strong predisposing cause. Children living 



ANATOMICAL LESIONS. 305 

in hospitals or any crowded institution ; those whose parents are poor or in 
want, and whose constitutions have been greatly deteriomted by long ill- 
ness, by the tubercular diathesis, or by acute disciises, are particularly apt 
to be attacked. It almost always follows upon some previous acute or 
chronic disease, particularly measles, or some other acute exunthem ; pneu- 
monia ; entero-colitis : hooping-cough ; long-continued malarious fevers, etc. 
MM. Guersant and Blache say {Diet, de Med., t. 28, p. OOn, "The exist- 
ence of some anterior disease is a necessary condition of gangrene of the 
mouth ; we have never known it, nor has M. Baron, to occur as an idiopathic 
affection.'' It has been affirmed by some persons to be confarjious, but this 
is exceedingly doubtful. The fact of its occurring sometimes in an endemic 
form has already been referred to. It has been known also to prevail as 
an epidemic. 

The ejcciting causes can rarely be ascertained with any certainty. The 
only one which seems to have been proved to exist in some instances is the 
exhibition of large doses of the mercurial preparations, and even this is 
questioned by some very good authorities. 

Anatomical Lesions. — Upon examination after death, it is found that 
the integinnent surrounding the mortified spot soon runs into putreftietion. 
The lip or cheek in which the disease is seated is swelled, hardened, tense, 
and shining, of a purple or greenish color, and presents a deep, circum- 
scribed engorgement. On the most prominent part of the swelling there 
often exists a rounded or oval, and distinctly limited eschar, of variable 
size, from a third of an inch to an inch, or even more, in diameter. In 
some instances the cutaneous slough is much larger, and extends irregularly 
to different parts of the face, to the chin, neck, eyelids, and even to the 
neighborhood of the ear, so as to occupy the whole of one side. Under 
these circumstances the tumefaction is neither so considerable, nor so 
regular, as when the slough is smaller. The eschar is always black, and 
generally dry and parchment-like, and extends a third or two-thirds of a 
line in depth, or quite through the integument. The tissues beneath the 
skin are not generally implicated, though in some cases the eschar is de- 
tached and there is a perforation of the cheek through which may be seen 
the alveolar processes. 

The mucous membratie of the mouth is always affected with mortification. 
The disease may be limited, so as to exist in the form of an elongated ul- 
ceration, of a dark grayish color, situated in the fold where the mucous 
membrane is reflected from the cheek to the lower jaw ; or, in a larger 
proportion of cases, it is seated on the internal surface of the cheek, oppo- 
site the inter\'al between the alveolar processes. Sometimes the disease is 
much more extensive, and occupies all or a part of the internal surface of 
the cheek. In such instances the whole thickness of the mucous tissue is 
destroyed, and it presents upon its surface a blackish or brownish pulta- 
ceous slough, almost liquid in consistence, which may be scraped off with 
a scalpel, leaving beneath hxifrc shred.-* of mucous membrane, without any 
trace of organization. The gums frequently participate in the di.sease, and 
are converted into shreds, or completely destroyed. 

The maxillary bones are sometimes, in severe cases, when the disease has 

20 



806 GANGRENE OF THE MOUTH. 

extended to the gums, exposed, blackened, and even necrosed. The teeth 
are very often uncovered and loosened, and not unfrequently some are lost. 
The tissues between the skin and mucous membrane are found either hard- 
ened and infiltrated, or sphacelated to a greater or less extent. In the 
least severe cases, the fatty cellular tissue, and the muscular structure of 
the cheek are infiltrated jwith serum, but preserve their organization. 
When the disease is more aggravated, the gangrene extends to these tissues 
also, and always to those adjoining the mucous membrane first; so that 
the cellular structure beneath that membrane, and then the muscles, are 
infiltrated with a sanious fluid, and either in a state of sphacelus or tending 
thereto, whilst some of the adipose tissue beneath the skin is §till merely 
infiltrated. In yet worse cases^ the sloughs formed on the two surfaces of 
the cheek come into contact, and if their separation from the sound parts 
has taken place, a perforation is the consequence. 

The condition of the bloodvessels in the midst of the diseased parts has 
been carefully examined by MM. Rilliet and Barthez. These authors 
state that when the tissues of the cheek are merely infiltrated, the vessels 
remain healthy, permeable, and their parietes are scarcely or very slightly 
thickened. AVhen the vessels run along the edge of the slough, they are 
still permeable, but their walls are thickened, and begin to assume the 
appearances of the mortified tissues. Lastly, when they traverse the' cen- 
tre of the eschar, they can still be traced out, but their canals are found 
obliterated by coagula, in the whole extent of the mortified parts ; or else 
the coagula occupy the vessels at their points of entrance into and exit 
from the slough, while between these points their walls are thickened, tend 
to assume the color and softness of the putrefied tissues, and their canals 
are filled with pultaceous gangrenous matter. The writers quoted do not 
suppose that the obliteration of the vessels is the cause of the sphacelus, 
since that change occurs only after the death of the surrounding tissues 
has already taken place. 

The disease very rarely occurs on both sides of the mouth at once, 
though this does occasionally happen. 

The submaxillary glands are nearly always in their natural condition, 
but in rare instances are softened and engorged. 

Gangrene of the mouth never, or very rarely, indeed, exists without 
lesions of other organs. Of these the most frequent are acute pulmonary 
affections, and after them, acute or chronic diseases of the gastro-intestinal 
tube, and then malarious fevers, pleurisy, pneumothorax, peritonitis, and 
nephritis. 

Symptoms ; Course ; Duration. — The following account of the symp- 
toms of the disease is taken chiefly from the work of MM. Rilliet and 
Barthez. Gangrene of the mouth generally begins during the course or 
convalescence of some acute or chronic disease, by ulceration, aphthae, or 
phlyctense of the mucous membrane, and, in rare instances, by oedema of 
the substance of the cheek. At the same time the face is pale, and usually 
continues so throughout the disease ; the nostrils and eyelids are often in- 
crusted, and the latter infiltrated or sunken, and surrounded by bluish 
circles; the lips are swelled and covered with scabs, or dry. The breath 



SYMPTOMS. 307 

of the child is fetid from the begiuuing, and, as the disease progresses, be- 
comes gangrenous. There is but little fever at first, unless the case be 
accompanied by some acute disease ; the pulse is commonly frequent and 
small in the beginning, rising gradually from 80 or 90 to 100 or 120, and 
becoming insensible towards the end. In cases occurring in the course of 
other diseases, the pulse rises sometimes to 120 or 140, and is larger and 
fuller. The child is generally languid and quiet at first, or more rarely 
cross and peevish. The strength may be either lost entirely, merely di- 
minished, or the patient may retain a sufficient amount of force to sit up 
and observe what is going on around, and even to leave the bed the day 
before death. Half the children observed by MM. Rilliet and Barthez, 
in whom this symptom was noted, sat up in bed until within a few days of 
the fatal termination. In most cases but little complaint is made of pain 
in the mouth, though in some it is said to be severe. 

The ulceration already spoken of as forming the first symptom of the 
disease is generally of a grayish color, and resembles very closely that 
which exists in the ulcero-membranous form of stomatitis. It may be 
seated either on the gums, in the fold formed by the junction of the cheek 
or lip with the gum, or on the inside of the cheek, opposite the space be- 
tween the alveolar processes. It may present a gangrenous appearance 
from the first day, or not until after two or three days ; or lastly, it may 
pass through the stages characteristic of ulcerative stomatitis, and termi- 
nate in the afiection under consideration. Dr. B. H. Coates {loc. cit.) de- 
scribes, under the title of gangrenous sore mouth of children, the ulcero- 
membranous form of stomatitis, and a few cases of gangrene, and states 
that three or four children out of 120 affected with ulcerated gums "suf- 
fered small spots of mortification, and one by the delay arising from the 
tardy report of a nurse, suffered necrosis in a portion of an alveolus." 

The ulcerations just described assume the following appearances as the 
gangrenous nature of the malady develops itself They become grayish, 
and then dark in color, bleed easily when touched, and are covered with 
pultaceous sloughs, exhaling a characteristic fetid odor. The gangrene 
extends to the neighboring parts, from the gum to the cheek, or from the 
cheek to the gum, and implicates at last the whole side of the mouth, or 
of the lower lip. At the same time the affected cheek or lip undergoes a 
circumscribed infiltration, which is at first rather soft, but becomes after- 
wards firmer, and forms at last a hard and rounded knot or tumor in the 
centre of the cheek, which is now tense, shining as though smeared witli 
oil, and pale, or marbled with purple spots, while the slough on the inside 
is of a brownish color, more extended in size, and sometimes surrounded by 
a dark ring. The hard tumor of the cheek just described usually aj)pear8 
between the first and third days after the sphacelation of the mucous mem- 
brane, though in some instances not until a later period. It is formed, as 
stated in the account of the anatomical lesions, by engorgement of the 
cellular and adipose tissues. The child, at this stage, is still aljle to sit up 
in bed and take notice, or shows evident signs of weakness and depression ; 
the face is swelled and destitute of expression on the affected side ; a 
bloody or dark-colored saliva runs from the mouth, which is partially 



308 GANGRENE OP THE MOUTH. 

open; the appetite is not entirely lost in all cases, the patient still de- 
manding and taking food ; vomiting is rare, but diarrhoea is almost always 
present; the thirst is generally intense ; the skin is warm and feverish, 
natural, or too cool, and almost always dry, the differences depending 
probably more upon the concomitant disease than upon the mouth affec- 
tion. The respiration is natural or altered according to the nature of the 
primary disease, ^vhich is, as already stated, in a large proportion of the 
cases, a pulmonary affection. The intelligence is generally undisturbed, 
though in some rare cases there is insomnia, delirium, or piercing cries. 

If the disease continues to progress, as it almost always does when it 
has reached the stage we are describing, there appears in many, but not 
all the cases (8 of the 21 observed by MM. Killiet and Barthez), a slough 
or eschar upon the most prominent and discolored part of the swelling of 
the integument of the cheek or lower lip. This generally makes its ap- 
pearance between the third and sixth days of the disease, but in other 
cases, as early as the second, or not before the twelfth, or even later. The 
skin, at the point where the eschar is about to form, becomes purple, and 
then black ; sometimes a phlyctena makes its appearance, which is very 
soon converted into a small, dry, black slough. This, if not limited by a 
process of separation from the living tissues, becomes larger and larger by 
the extension of the sphacelation, until it may, as already stated, embrace 
the whole side of the face. In grave and fatal cases, the gangrene some- 
times extends to all the tissues of the cheek, and meeting at last, the dis- 
ease which had commenced on the inside of the mouth, occasions a per- 
foration, through which may be seen the teeth, alveolar processes, and the 
whole interior of the buccal cavity. In such instances as these, several of 
w^hich w^e have seen in the Pennsylvania and Philadelphia Hospitals, the 
appearance presented by the child is, as may well be imagined, of the 
most pitiable kind. Even under these circumstances, however, with the 
cheek perforated, the edges of the opening irregular and covered with 
shreds of dead tissue, the gums destroyed, the teeth loosened, and the 
maxillary bones exposed, blackened, and perhaps necrosed, with a dark 
and fetid sanies flowing from the mouth or perforation, and a putrefactive 
smell infecting the air around, the child may retain, in some instances, its 
strength, so as to sit up in bed, ask for food, and drink with avidity. In 
other cases, on the contrary, the patient, at this stage, is exhausted to the 
last degree, and refuses both food and drink. During the closing stage of 
the disease there is generally profuse diarrhoea, rapid emaciation, dry skin, 
small, rapid pulse, and at last death in a state of utter prostration. 

In favorable cases the recovery may take place in the early stage, before 
the integument becomes involved, and while the gangrene is limited to the 
mucous membrane, or at a later period, after the slough has separated. 
In the first instance the child generally recovers without deformity, though 
we saw one case in which necrosis of about an inch of the front of the in- 
ferior maxilla took place, without any loss of the soft parts. When the 
child recovers after the formation of the cutaneous slough, a very rare 
event, the gangrene ceases to extend, the eschar separates and is cast off, 
the edges of the opening assume the appearances of a healthy ulcer, and 



DIAGNOSIS. 309 

after a length of time approach each other ami cicatriz^e, leaving generally 
a large, uneven, discolored scar, like that of a burn, which remains through 
life a horrid deformity. 

The duration of the disease varies according to its termination. When 
this is unfavorable, which happens in much the larger proportion of cases, 
death usually occurs about the end of the first, or in the course of the 
second week, though it has been known to occur at a later period. In 
favorable cases the duration is commonly longer, particularly if a cutane- 
ous eschar has been produced, as the separation of the slough and cicatri- 
zation of the ulcer which remains require a tedious and slow process on 
the part of nature. 

Complications are very apt to arise in the course of the disease. The 
most frequent is pneumonia. MM. Guei*sant and Blache state that it 
exists in nine-tenths of the cases; MM. Rilliet and Barthez found it in 19 
out of 21 ; of the 19, it began in 8 during the progress of the gangrene, 
and apparently under the influence of the latter, whilst in the remaining 
cases it existed before, and acted perhaps as a predisposing cause to the 
afl^ection of the mouth. Another and more dangerous complication is the 
occurrence of gangrene in other parts of the body, particularly the soft 
palate, pharynx, oesophagus, anus, and more frequently the vulva and 
lungs. 

Diagnosis. — Some authors have described as identical affections, under 
the title of gangrenous stomatitis, the disease under consideration and the 
one already treated of as ulcero-membranous stomatitis. This has been 
done particularly by M. Taupin, who is followed in his description by M. 
Valleix (Guide du Med. Prat, t. iv). It seems clear to us, moreover, that 
Dr. B. H. Coates, in his very valuable paper on the "gangrenous sore 
mouth of children " (loc. cit.), mingles in his description the two diseases 
referred to. It seems clear, however, that the diflTerences between them as 
to frequency, symptoms, course, amenability to treatment, and termina- 
tion, which are fully pointed out in the diagnostic table below, fully war- 
rant us in regarding them as different and distinct diseases. 

The diagno.sis of gangrene of the mouth is, in most cases, very easy. 
The ulceration of the raucous membrane, followed by gangrene ; the deep- 
seated induration of the cheek, at first pale on the outside, then dark -col- 
ored, and terminating after a time in a characteristic slough ; the course 
of the malady, and the nature of the general symptoms, will generally 
prevent any difficulty in the recognition of the disease. 

From stomatitis it may be distinguished by attention to the points laid 
down in the following table taken from M^T. Killiet and Barthez : 

STOMATITIS. OANORENE. 

B^-uins by ulceration or by pseudo- Begins by iilceration, which is some- 
membranous plastic deposit. times grangrcnons from the first, or by 

oeti'-ma of the cheek. 

Odor very fetid and sometimes gangre- Odor always gangrenous. 
nous. 

But little extension of the local lesion, Considerable and rapid fxtonsion ; the 

which always retains the same apfKjar- tissues assume a peculiar dark grayish 

ances. tint. 



310 GANGRENE OF THE MOUTH. 

STOMATITIS. GANGREJfE. 

But little swollin^of the cheek or lips, Extensive swelling and oedema of the 

or simiil}' oedema of those parts, without cheek, with deepseated induration, ten- 

deepseated induration, tension, or unctu- sion, unctuous appearance, purple spots, 
ous appearance. 

Salivation rarely so considerable as to Salivation abundant; constant escape 

flow from the mouth ; when present some- of fluid, at first sanguinolent, afterwards 

times sanguinolent; never mixed with putrefactive. 
shreds of gangrenous tissue. 

Never an eschar on the exterior. Often an eschar upon the cheek or 

lips. 

Never complete perforation of the soft Perforation of the soft parts frequent; 

parts; denudution of the bones never oc- denudation of the bones constant; 

curs ; loss of the teeth very rare. loosening of the teeth constant, ^nd 

their loss frequent. 

Course of the disease slow when left to Course rapid, and termination fatal, 

itself; recovery rapid under the influence as a rule, when the disease is left to 

of treatment. itself, and in spite of all treatment. 

Gangrene of the mouth may be confounded with malignant pustule. 
The method of diagnosis has been drawn by M. Baron in the following 
words : " Malignant pustule always begins on the exterior ; affects the epi- 
dermis first, and extends successively to the corpus mucosum, chorion, and 
subjacent parts ; whilst on the contrary, the gangrene under consideration 
attacks the mucous membrane first, then the muscles, and lastly the skin." 

Prognosis. — The prognosis of true gangrene of the mouth is exceedingly 
unfavorable. The great majority of the subjects die in spite of all that 
can be done. Dr. Coates {loc. eit, p. 14) says that a black spot on the 
outer surface of the swelling " has always been in my own experience the 
immediate harbinger of death. It is proper to state, however, that I have 
heard it said that cases had recovered in this city, in which the gangrene 
had produced a hole through the cheek." MM. Rilliet and Barthez state 
that "death is the ordinary termination of gangrene of the mouth ; though 
there are instances of recovery on record." Of 29 cases analyzed by them, 
only 3 recovered. MM. Guersant and Blache (^loc. cit, p. 596) state that 
unless arrested in the formative stage, it ends fatally almost constantly in 
from five to ten days, and frequently before perforation has taken place. 
Of 36 cases observed by M. Taupin in the Children's Hospital at Paris, 
not one escaped (Guersant and Blache, loc. cit, p. 597). The authors of 
the Compendium de Medecine Pratique say of this disease (t. i, p. 632), 
" Death is the almost inevitable termination." Dr. Marshall Hall {Edin. 
Med. and Surg. Journ., xiv, p. 547) reports six cases of the disease, two of 
which followed measles, one repeated attacks of pneumonia, one fever 
(type not mentioned), one worm fever, and one typhus fever. All but one, 
the case occurring in the course of typhus fever, in a girl, twelve years old, 
died. This girl recovered, with, however, falling in of the right cheek, 
"a frightful chasm" on the left side of the mouth, and caries of a portion 
of the alveolar process, palate bone, and second molar tooth. Recoveries 
sometimes occur, however, as in the case mentioned by Dr. Hall, after 
perforation, but nearly always with terrible deformities, with adhesions of 
the walls of the mouth to the jaws, with incurable fistulse, etc. 



I 



TREATMENT — LOCAL APPLICATIONS. 811 

The prognosis is more favorable iu private practice tbau in hospitals. 
The tavorable circumstances iu any case are: good hygienic conditions ; 
vigorous constitution of the child ; the absence of dangerous concomitant 
disease ; the continuance of appetite and strength ; and a disposition to 
limitiition and separation of the slough. Unfavorable symptoms are weak 
and debilitated constitution of the patient ; severe coexistent disease ; pros- 
tration of the strength ; and extension of the sloughing process. Death 
may also occur from hemorrhage in consequence of the separation of the 
sloflgh, as iu a case quoted from Hueter by Bouchut. 

Tkeatmext. — The reader need but refer to the remarks on prognosis 
to be assured that no treatment as yet discovered promises much success. 
We would call attention also to the following statement, — that the remarks 
about to be made apply only to true gangrene of the mouth, and not to 
all the cases described by some writers under the title of gangrenous sore 
mouth or even that of gangrene of the mouth, since, as already stated, they 
confound together true gangrene and ulcero-membranous stomatitis. 

The treatment is divided into local and generaL The local treatment 
recommended by the French writers., consists in cauterization of the slough- 
ing parts with one of the mineral acids, with nitrate of silver, or with the 
actual cautery. This is the plan proposed by MM. Billard, Baron, Guer- 
sant and Blache, Barrier, Rilliet and Barthez, Bouchut, and Valleix. 
The authors of the BihUoth>qu€ d-e Mcdecin Praticien remark, however, 
that nearly all the patients subjected to cauterization die, and that of the 
small number saved, there are as many who had not been subjected to that 
treatment, as there are of those to whom it had been fully applied. They 
wonder, therefore, that recent authors continue to repose the same confidence 
in it, as did their predecessors. " For us," they say, " we are of opinion 
that cauterization exerts but slight influence, if it have any at all, and it 
is greatly to be desired that the zeal of practitioners might discover some 
more efficacious remedy" (loc. ct't., t. v, p. 551). 

It is very important to make use of the caustic application as early after 
the beginning of the sphacelus as possible, for if it be allowed to spread to 
any considerable depth or extent, there is scarcely a hope of arresting it 
by any means. MM. Guersant and Blache recommend pure nitric, sul- 
phuric, or muriatic acid ; MM. Rilliet and Barthez propose the acid nitrate 
of mercury, or muriatic, sulphuric, or acetic acid ; M. Valleix proposes the 
treatment employed by M. Taupin, which is to remove the pseudo-mem- 
brane and a part or the whole of the gangrenous eschar with scissors, to 
make some scarifications upon the healthy part", to apfily pure muriatic 
acid, and after the fall of the slough, to make use of dry chloride of lime 
(calx chlorinata). The acid most generally employed is the muriatic. 
The local treatment proposed by MM. Rilliet and Barthez is the follow- 
ing: As sf>on as the ulcerations assume a gangrenous appearance, to touch 
them with a brush or sponge dipped into acid nitrate of mercury, or pure 
muriatic acid, the brush to remain in contact with the sloughs for a few 
instants, and then to be applied rapidly around and on the parts beyond 
them. After this cauterization, an application is to be made of dry 
chloride of lime (in the manner recommended in the article on ulcere- 



312 ^^T^NQRENE OF THE 

membranous stomatitis), which is to be left in contact with the sloughs for 
a few minutes, when the mouth must be thoroughly washed with a strong 
jet of water from a syringe. The cauterization and use of the chloride of 
lime are to be resorted to twice a day, and the mouth washed three or four 
times in the interval with large injections of simple water, barley-water 
mixed with honey of roses, or better still, with a strong decoction of 
cinchona. If the case goes on favorably, and the sloughs separate, the 
cauterizations are to be suspended, and the chloride of lime alone em- 
ployed. If, on the contrary, a slough forms on the outside of the cheek, 
a crucial incision must be made into it, and a brush charged with the 
same caustics introduced between the cuts; powdered cinchona is then 
placed in the openings, and retained there by a piece of diachylon plaster 
or by pledgets of charpie, dipped in a solution of soda. This treatment 
is to be continued until the slough separates, when the edges of the wound, 
and all the diseased parts that can be reached, are to be cauterized. 

In applying escharotics to the mouth, certain general precautions are 
required, of which it is necessary to give some account. When th6y are 
used upon the inside of the cheek, a spoon must be introduced into the 
mouth, with the concavity directed towards the alveolar processes, in 
order to preserve the teeth and tongue from being touched. When the 
application is made upon the gums, the cheek should be drawn to one side 
by an assistant, and the tongue pushed out of the way with the finger, or 
a spoon. If the acid happen to touch the teeth or tongue, it must be 
instantly washed off. The mouth ought always to be thoroughly cleansed 
with water immediately after the cauterization, to remove any super- 
abundance of acid. 

The kind of brush most suitable for the application of the mineral acids 
is one made of charpie, strongly tied to a solid handle. The sponge-mop, 
which is sometimes used, is made by fastening a small piece of fine sponge 
to the end of a stick. 

MM. Guersant and Blache recommend that the acid be applied to the 
slough every hour, until the sphacelus ceases to extend. They state that 
this plan is sometimes advantageous when the gangrene is confined to the 
gums only, but that it is generally powerless when the disease has ex- 
tended to the cheek, or has implicated the deepseated tissues. Under the 
latter circumstances, and when the inefficacy of caustics has been shown by 
trial, they propose the use of the actual cautery, as recommended by M. 
Baron, and other distinguished practitioners, and which, they add, has 
afforded them some brilliant results in very bad cases. 

M. Barrier advises that we should accurately expose the diseased parts 
by crucial incisions, and apply the escharotic to all the parts forming the 
limits of the gangrene, in such a way that the tissues already disposed to 
slough shall be thoroughly cauterized, while those a little beyond are so in 
a less degree. 

In applying these powerful caustics, several authorities recommend the 
administration of an anaesthetic. 

The English writers, and those of our own country, seem rather less dis- 
posed than the French to make use of powerful escharotics, and lay more 



TREATMENT — LOCAL APPLICATIONS. 813 

stress upon the general treatment. Underwood, following Dease, of Dublin, 
advises that "the parts should be washed and likewise injected with muri- 
atic acid, in chamomile or sage tea, and afterwards dressed with tlie acid, 
mixed with the honey of roses, and over all a carrot poultice." Dr. 
Symonds (Lib. of Pract. }fed., vol. iii, p. 23) directs the cheek to be fre- 
quently rubbed with a stimulating embrocation of camphorated oil and 
ammonia, on the first appearance of the swelling, and in the intervals to 
be kept moist with a tepid lotion containing muriate of ammonia and 
alcohol. On the slightest appearance of an eschar upon the interior of 
the mouth, it is to be touched with solid nitrate of silver, or strong muriatic 
acid. If slougliing have already commenced, the nitrate of silver lotion 
is said to be the best application. The mouth is to be frequently washed 
or syringed with a solution of chloride of soda, and when mortification has 
taken place, we are to endeavor to prevent it from spreading, by carrot or 
fermenting poultices. Maunsel and Evanson say that the early application 
of muriatic acid, undiluted, or mixed with one or two parts of honey, is the 
only efficient application in these forms of gangrene. Dr. Fleming (Dublin 
Hosj^. Gaz., May 1st, 18G5) recommends the application of a concentrated 
solution of nitrate of copper, to the sloughing surfaces, and also paints the 
circumference of the disease and the surrounding cheek with collodion, 
which, he believes, acts favorably upon the capillary circulation of the 
part. Dr. Gerhard (Lib. of Pract. Med., vol. iii, Am. ed., p. 24) says, 
"The best local applications are the nitrate of silver, if the slough be 
small in extent; if much larger, the best escharotic is the muriated tinc- 
ture of iron, applied in the undiluted state : after the progress of the dis- 
ease is arrested, the ulcer will improve rapidly under an astringent stimu- 
lant, such as the tincture of myrrh, or the aromatic wine of the French 
Pharmacopreia." Dr. Dungli.son (Prac. of Med., vol. i, p. 36) recommends 
the application with a brush, of a mixture of equal parts of creasote and 
alcohol, after incisions have been made through the gangrenous parts. 
Dr. Condie (op. cit., 6th ed., p. 174) states that he has found a strong so- 
lution of sulphate of copper (thirty grains to the ounce of water), applied 
very carefully twice a day, to the full extent of the gangrenous ulceration, 
by far the mo.st successful lotion. 

We have, ourselves, lately employed carbolic acid in two severe cases. 
The pure acid was carefully applied to the sloughing ulcer on the inside of 
the cheek, and subsequently a solution of one part of the acid in fifty of 
water, was frequently employed to wash out the mouth. The application 
of the undiluted acid seemed to have a beneficial effect, by checking the 
progress of the sloughing, and completely destroying the putridity of the 
dead ti.ssue which had not as yet separated. One of the cases recovered 
quickly, without perforation of the cheek ; but in the other death occurred, 
with .symptoms of profound adynamia, though there was little, if any, ex- 
tension of the gangrene. 

It seems to us very clear, after the study of the treatment recommended 
by the different writers quoted above, that the moat important part of the 
local management of the di.sease is the early application of some escharotic 
substance to the ulcerations, or to the mortifying parts ; the best is probably 



314 GANGRENE OF THE MOUTH. 

pure muriatic acid. This should be made use of twice or three times a day, 
observing the precaution to wash the mouth with water, immediately after- 
w^ards, by means of a syringe. Later in the disease, when it has extended 
to the skin, the use of escharotics, or of the actual cautery, is still recom- 
mended by many writers, but opposed by others. We confess we should 
be inclined to prefer, at this stage, the use of muriated tincture of iron, as 
recommended by Dr. Gerhard, of carbolic acid as used by ourselves, of 
strong lotions of sulphate of copper, of solutions of nitrate of silver of 
moderate strength, or of the dressings of muriatic acid and honey of roses, 
as proposed by Underwood, in connection with carrot and fermenting poul- 
tices, as recommended by Underwood and Symonds. Throughout the 
course of the disease the mouth ought to be frequently cleansed by wash- 
ing or injecting with solution of chlorinated soda, mixed with eight parts 
of water, or with a dilute solution of carbolic acid, which corrects at the 
same time the terrible fetor of the disease. 

The importance of these measures can scarcely be overestimated, since 
the presejice of gangrenous tissue about the oral cavity must lead to the 
introduction of the poisonous results of putrefaction into the system, both 
by the fetid discharges which partly flow down the oesophagus, and still 
more by the contamination of the inspired air. Indeed, it seems quite pos- 
sible, as urged by Dr. Keiller (Edin. Med. Jour., April, 1862), that in cases 
of unchecked gangrene of the mouth, death occurs in a great measure, 
from secondary blood-poisoning, resulting from the continued and unavoid- 
able inhalation of air poisoned by emanations from the gangrenous sloughs. 
It is evident, therefore, that local applications, both of caustics and anti- 
septic lotions, must be of great service, by arresting the sloughing and cor- 
recting or checking the foul discharges. 

General Treatment. — All writers recommend the use of tonics, stimu- 
lants, and nutritious diet, unless the presence of high fever, or the state of 
the digestive organs, seems to contraindicate their employment. From our 
own personal experience in the treatment of this affection ; from a consid- 
eration of what we have seen most successful in other forms of gangrene, 
as that following accidents and surgical operations in deteriorated consti- 
tutions ; from what proved effectual in a case of idiopathic gangrene of 
the vulva, in a child ten years of age, which came under our charge ; and 
from what is necessary in that analogous condition of the constitution 
which accompanies typhoid and cachectic diseases, we are induced to be- 
lieve that the general treatment must be of at least as great importance as 
the local, and that the steady and persevering use of tonics, stimulants, 
and of the most strengthening diet, should always be insisted on from the 
earliest period, whether fever be present or not. The quantity of stimu- 
lants, and the amount of food, ought, it seems to us, to be measured only 
by the capacity of the digestive organs to receive and assimilate them. 
Of the tonics, the best are quinine and muriated tincture of iron, which 
may be given in syrup, in doses of a grain of the former with from three 
to five drops of the latter, four or five times a day, to a child three or 
four years old. The most suitable stimulants are very fine old brandy, 
Madeira wine given in considerable quantities, and, if the stomach is sure 



THRUSH. 315 

• 

to receive it well, carbonate of aniinouia, or better still, the aromatic 
spirit of hartshorn. The diet must consist of milk made into punch with 
brandy, wine-whey, the yelk of eggs beaten up with wine, strong soups 
and beef tea, animal jellies, and, if the child wish it, tender meat finely 
minced. 

The room in which the child is placed ought to be large, if possible, and 
at all events thoroughly ventilated. 



ARTICLE V 



THRUSH. 



Definition ; Synonyms ; Frequency' ; Forms. — Thrush is associated 
with the growth of a peculiar fungus, the oidium albicans (Robin), and 
appears as a deposit upon the raucous membrane of the mouth, of a whitish 
or grayish-yellow exudation, of a soft cheesy consistence, at first adherent, 
and afterwards spontaneously detached, and generally unaccompanied by 
ulceration of the tissue beneath. This constitutes the whole disease in 
some cases, no other lesion being discoverable ; whilst in other instances, 
and probably in a large majority, it is connected with some more or less 
serious general or local disorder. It is the disease described under the title 
of aphtha? or thrush, by Underwood and Eberle ; of aphth?e, by Dewees ; 
of er}'thematic stomatitis, with curdlike exudation, by Dr. Condie ; and of 
aphtha lactantium, aphtha lactamen, and aphtha infantilis, by the older 
writers. It is the muguet of the French. 

The freqmnaj of the disease is very great in hospitals for children. It 
is common also amongst the children of the poor, and comparatively rare in 
the middle and upper classes of society. It occurs under two forms, the 
idiopathic or primary, and injmptomatic or secondary. By the first is meant 
the form in which the affection of the mouth is the only perceptible lesion ; 
by the second, that in which disease of other organs or of the constitution 
generally, precedes the buccal exudation. 

Causes. — Pkedisposixo Causes. — The disease occurs at all a^ex, but 
is by far most common during the first two months of life. Altered health 
from any cause, deficient ventilation, and ivant of cleanliness, strongly pre- 
di.«pose to the production of thrush. Miich diflTerence of opinion exists as 
to the nature of the connection between enf^riti^ and thrush, especially 
since the publication of the researches of M. Valleix, who thinks that the 
latter disease is almost always the consequence of the former, and who 
doubts the existence of purely local cases of thrush. MM. Trousseau and 
Del[>ech, on the contrary (Joum. de Med. de MM. Beau ei TroxiMean, Jan- 
uar}', Februar}', April, May, 1845 \ report 14 cases out of 58, in which 
there was neither gastric nor intestinal coniplication, and others in which 
enteritis did not occur except as a conserpience of thrush. They state, 
however, that though enteritis does not exist in all ra-ps, and is a simple 



316 THRUSH. 

complication in others, it is sometimes the true cause, the sole origin of the 
disease. Again Dr. Berg, in a very accurate and careful history of the 
disease (Brit and For. Med. Rev., October, 1847, p. 429) in which he de- 
monstrates its cvyptogamic nature, states " that both the local and general 
symptoms which accompany thrush in the child are, in most cases, imme- 
diate or secondary consequences of the presence of the parasite, and not 
to be regarded as the causes of that fungoid vegetation." It is believed 
by many observers to be contagious. This opinion is rendered doubtful, 
however, by the assertion of MM. Baron, Billard, Guersant, and Valleix 
{loc. cit., t. iv, p. 63), that they have known children in health to be fed 
with the same spoon which has been used for others affected with the dis- 
ease, without their contracting it. M. Bouchut on the contrary, and Dr. 
Berg (loc. cit.), both of whom believe in the cryptogamic nature of thrush, 
assert it to be contagious. Dr. Berg is of opinion that it is " conveyed 
from one patient to another by sporules or fragments of sporules, in the 
dried state, floating in the atmosphere, but that still more frequently it is 
propagated by the bottles from which children with thrush have been fed, 
or by the nipple, especially where, as in many hospitals, two children are 
suckled by one nurse." This gentleman made many experiments in order 
to decide this question, all of which proved favorable to the idea of con- 
tagion. 

Of various predisposing causes which have been cited as productive of 
the disease, the ones most generally admitted are the use of artificial diet, 
particularly one consisting of farinaceous substances, and, in children who 
are suckled, an unhealthy state of the nurse's milk. To show the truth of 
these assertions, we make the following quotations. Underwood says : " A 
principal remote cause of this disease seems to be indigestion, whether pro- 
duced by bad milk, or other unwholesome food, or by the weakness of the 
stomach." Dewees remarks that " children fed much upon farinaceous 
substances are especially exposed to the attacks of this disease, particularly 
when their food is sweetened with brown sugar or molasses." Dr. Eberle 
says: "Unwholesome and indigestible nourishment, and overdistension of 
the stomach, during the early stages of infancy, almost inevitably lead to 
the occurrence of aphthae (thrush). Bad and old milk, and thick farina- 
ceous preparations sweetened with brown sugar or molasses, are especially 
apt to give rise to the disease." • Much influence is ascribed by Dr. Berg 
to the operation of artificial food in favoring the growth of thrush. M. 
Valleix {loc. cit, p. 60), who has studied the subject with the greatest care 
and attention, says that amongst the hygienic conditions which may act as 
predisposing causes " one alone has seemed to me to exert a positive influ- 
ence, and this is improper alimentation." He adds, that since the publica- 
tion of his Clinique, he has several times met with cases of thrush, " and 
I have always found that the children had been put upon feculent diet. 
On the other hand, I have never known a child to have the disease, who 
had been suckled exclusively during the early months of life." MM. 
Trousseau and Delpech, in the very valuable paper on muguet (thrush), 
already quoted, say: "We would be justified, therefore, in asserting, that 
we have never known an infant to die of thrush, who had been suckled at 



ANATOMICAL LESIONS. 317 

a healthv breast, or whose health had uot been dangerously compromised 
by other causes.'' To show iu another mode the influence of this cause, 
we will state that of 29 cases of the disease observed by these gentlemen 
in children who were suckled, only 7, or one-fourth, died ; whilst of 22 
in those who were not suckled, 17, or more than three-fourths, died. 
Our own experience is precisely that of ^IM. Valleix, Trousseau, and 
Delf>ech. 

Season exerts a considerable influence upon the production of thrush, as 
M. Valleix found that more than half the cases occurred during the three 
warmejit months of the year. 

Excitiufj Oiiists. — The deprivation of the breast, and a consequent resort 
to artificial diet, particularly one consisting of farinaceous substances, is 
probably much the most frequent exciting cause of thrush. An unhealthy 
state of the milk of the nurse will also act as an exciting cause. We have 
met with two cases of the disease, one of them fatal, which appeared to 
depend uix)n the latter circumstance. Dr. Berg believes that prolonged 
sleep from any cause disposes to the disease, by favoring the growth of the 
parasite, or by so changing the secretions of the mucous membrane of the 
mouth, as to render them important agents in augmenting the disorder. 
An acid state of the buccal secretion is cited as a cause by many authors, 
and is clearly proved to exist in a great many instances. 

Anatomical Lesions. — The characteristic deposit is found upon the 
mucous membrane of the mouth, pharynx, cesophagus, and in rare cases, 
of the stomach and intestines. The question of the possibility of the ex- 
tension of thrush to the gastric mucous membrane has been much dis- 
cussed, and the highest authorities have been almost equally divided upon 
it. This disagreement has arisen solely from the want of microscopical 
examination, which enables the observer to distinguish readily between 
true thrush and other appearances of the gastric mucous membrane which 
closely resemble it. The most conclusive demonstration of its occurrence 
upon the mucous membrane of the stomach has been recently furnished in 
a valuable article on this subject, by M. J. Parrot (Arch, de P/njsiologie 
Norm, et Path., Nos. 4 and 5, 1869) ; and in a still more recent article (id. 
op., vol. iii, 1870, p. 621), he has also determined the possibility of its de- 
velopment in the large intestine. It is a curious fact, and a very impor- 
tant one, insisted upon by MM. Trousseau and Delpech, and other ob- 
servers, that the false membrane never extends to the nasal or air-passages ; 
and they call attention to the singular diflerence in this respect between 
the aflTection under consideration and diphtheritic inflammation, which at- 
tacks almost exclusively the nostrils, pharynx, larynx, and bronchia. It 
ap|)ears, however, from recent observation, that the peculiar growth of 
thrush has been found upon both the epiglottis and the inferior vocal cords; 
and Parrot (loc. cit.) gives the details of a ca.se in which the fungus was 
found in the air-vesicles of one lung. 

Lesions of the digestive mucous membrane are met with iu nearly all 
the cases. M. Valleix states that softening of the gastric mucous mem- 
brane is almost constant, and that it is often accompanied by redness and 
thickening. The authors cited above are of opinion that the gastric 



318 THRUSH. 

lesions have been greatly exaggerated, and assert them to be much the 
same as exist in other diseases foreign to the digestive apparatus. Various 
morbid alterations of the mucous membrane of -the intestines exists in 
nearly all fatal cases. This fact is acknowledged as well by MM. Trous- 
seau and Delpech, who deny the invariable connection of these alterations 
with thrush, as by M. Valleix, who asserts the connection almost without 
reserve. In nearly all cases the mucous membrane of the large intestine 
presents some of the following lesions, which are mentioned in the order of 
their frequency : thickening, injection, softening, or ulceration. In the 
ileum are found, in a great many cases, injection, softening, or thickening 
of the mucous membrane, unusual development of the mucous follicles, and 
tumefaction and ulceration of the glands of Peyer. 

In severe symptomatic cases a certain amount of erythematous inflam- 
mation is commonly found upon the skin of the buttocks and thighs, and 
ulcerations sometimes exist upon the inner ankles. Traces of inflamma- 
tion sometimes, but very rarely, exist in the membranes of the brain, and 
the lungs not unfrequently present the lesions of secondary pneumonia. 
Before leaving this part of the subject, we may remark that in the few 
cases we have met with in private practice, no ulcerations occurred upon 
the malleoli, and the erythema was observed only in the neighborhood of 
the anus. 

Dr. Dewees describes the autopsy of a child who died about the end of 
the first month of life, of what he designates as aphthae. The lesions coin- 
cide so closely with those which are characteristic of thrush, that we will 
quote the description, in order that the two may be compared together by 
the reader. " We found the whole tract of the oesophagus literally blocked 
up with an aphthous incrustation, to the cardia, and there it suddenly 
stopped. The inner coat of the stomach bore some marks of inflammation, 
as did several portions of the intestines; but not a trace of aphthae could be 
discovered below the place just mentioned." In the previous description 
of the case, he says that coat after coat of aphthae were thrown off, and 
each new crop appeared to be more abundant, and less amenable to reme- 
dies. {Dewees on Children, pp. 304-305.) 

Dr. Eberle says : " I have myself had an opportunity of examining the 
body of an infant, that had died of this disease (aphthae or thrush). In 
this case the aphthae were very distinct, throughout the whole course of the 
oesophagus. The stomach and bowels presented nothing that bore any re- 
semblance to this eruption ; but there were decided marks of inflammation 
in the mucous membrane of the small intestines, with a vast number of 
minute superficial ulcerations, and larger patches of softening of this tissue, 
throughout the colon and lower part of the rectum." {Diseases of Chil- 
dren, pp. 172-173.) 

Symptoms. — We shall first describe the characters of the exudation, and 
then proceed to the consideration of certain general and local phenomena 
which exist to a greater or less extent in both forms of the disease. 

The mucous membrane of the mouth is often somewhat red, dry, and 
tender for a longer or a shorter time (generally from one to three days), 
before the appearance of the exudation, and at the same time the papillae 



SYMPTOMS. 319 

of the tongue swell and become protuberant. Next the exudation shows 
itself in the form of small, whitish point;?, sometimes on the tongue fii-st, 
and in other cases on the inside of the lips, whence it extends to the 
cheeks in idiopathic mild cases, and to the roof of the mouth, soft palate, 
pharynx, and tvsophagus, in the grave symptomatic form. The points of 
false membrane tirst deposited rapidly increase in size and thickness, so 
that in from one to three or four days, they assume the form of large 
patches, or a continuous membrane, which covers the whole or a consider- 
able portion of the cavity of the mouth. When the exudation is recent, 
it is thin, and its surface smooth; when, on the contrary, it has been 
longer deposited, it becomes thicker, and its surface is rough. It is at 
first of a milk-white or pearly hue, but when undisturbed assumes a gray- 
ish or yellowish color. It is soft in consistence, breaking down under the 
finger like cheese, and presenting no traces of organization to the naked 
eye. It adheres to the mucous membrane with considerable tenacity at 
first, but becomes looser after awhile, and is detached spontaneously at last 
without any lesion of the tissue beneath. 

The foregoing description applies to the exudation as it appears to the 
unassisted eye. We pass next to give an account of the characters it pre- 
sents, when subjected to microscopical examination, and in so doing shall 
quote the language of Berg, who first discovered that thrush essentially 
depended upon the presence of a peculiar parasitic fungus, to which Robin 
has given the name of oidium albicans. Dr. Berg {loc. cit.) states, that 
the white coating of the exudation consists of epithelium, thickened by 
the swelling of its constituent cells ; from the epithelium there springs a 
parasitic fungus in greater or less quantity, so that the chief portion of a 
patch of aphtha* (thrush) is composed either of epithelium or else of the 
parasitic growth. Under a magnifying power of from 200 to 300 diam- 
eters, an aphthous crust is seen to consist of epithelial cells, with a more 
or less interwoven coat of fibres, and a variable number of spherical or 
oval cells, without any sign of exudation-corpuscles, but only a small 
quantity of molecular albuminous deposit. "We can often trace the suc- 
cessive development of these cells from a spherical one of the smallest 
size, to an oval cell, and thence to a filament; and we have no doubt our- 
selves that the smaller cells are sporules, out of whose development the 
larger oval cells are formed, and finally, the filaments in the same manner 
a.s has been observed in other fungoid growths of this nature." Numer- 
ous projecting fibrils are observed in the circumference of an aphthous 
cru.st when submitted to the microscope ; but these are rendered infinitely 
more clear by a weak solution of potash, which di.ssolves the albumen, 
and renders the cells of the epithelium transparent, while, at the same 
time, it diminishes their intimate cohesion, and the network of vegetable 
fibres is more plainly seen. "These fibres are cylindrical, with sharply 
defined dark e<lges, and their centres are tran.sparent in transmitted light; 
they are generally equal in thicknes-, but at times they are, as it were, 

knotted together, and divided by distinct walls of separation In 

their interior, these fibrils often exhibit nucleated cells; occasionally these 
are ver}' numerous, and of small size, but at times they are larger. lu 



320 THRUSH. 

their course the fibrils divide into numerous branches, whose diameter is 
not less than that of the original stem, and I have occasionally observed 
these ramifications to increase in thickness, at their free extremity, and to 
terminate in a club-shaped end with a species of cell. From the sides of 
the fibrils spring numerous sporules, forming a point of departure for new 
ramifications. .... Careful investigation has shown us that these cells 
are placed upon the sides of the fibrils, and in particular that they are 
congregated around the terminations of the latter. It must, therefore, be 
admitted that the cells and the fibrils are both constituent parts of one 
and the same organization. When this growth vegetates undisturbed, its 
fibrils penetrate between the layers of the epithelial cells, but do not ex- 
tend deeper than the inferior layer, though they spread laterally in every 
direction. On the free surface of the epithelium, the ramifications rise 
above the surface, exhibiting at the same time an abundant fructification, 
which gives a yellowish hue to the exterior." 

M. Parrot, in describing the appearances of thrush upon the gastric 
mucous membrane, states that the disease presented itself in the form of 
small prominent rounded masses, of yellowish color, and either isolated or 
in groups. These were adherent to the mucous membrane, nearly all um- 
bilicated, and upon pressure the central depression became filled with a 
cheesy-looking material. On microscopic examinations of sections, the 
spores and filaments of the muguet were found infiltrating the tissue, and 
as it were planted there, at times scattered in small numbers, at others ac- 
cumulated in large masses, and holding between them many oil-drops and 
some debris of the mucous membrane. The muscular coat of the stomach 
was not involved, but in some instances the spores and filaments pene- 
trated the mucous membrane, and extended to the submucous space. In 
other cases the mucous membrane was only superficially involved. 

The reader is referred for a more full account of the cryptogam ic theory 
of thrush to the interesting review of Berg's work above quoted, and to 
Bouchut's work on the diseases of new-born children ; and for a complete 
description of the oidium albicans to the work of Robin, Histoire Natu- 
relle des Vegetaux Parasites, Paris, 1853 ; the articles of Parrot above 
quoted; and the article on thrush in Vogel's work on the Diseases of Chil- 
dren (Amer. ed., 1870, p. 99). 

Symptoms of the Mild Form of Thrush. — This form is the one most fre- 
quently met with in private practice. It is mild in all its characters, and 
often presents no other symptoms than those connected with the mouth. 
These are heat and dryness, with tenderness of that part. The tenderness 
is shown by the child's crying and jerking the head backwards when the 
finger is introduced into the mouth, whereas, in health, the infant will 
almost always seize the finger and suck it with considerable force. It is 
shown, also, by the refusal to take the breast, or by the difficulty with 
which this is done, the child occasionally letting the nipple drop with a 
cry of pain, then seizing it again, and again dropping it with fretting or 
screaming. In some of the cases there are various signs of disorder of 
the digestive tube, which are, however, seldom severe. They consist of 
slight diarrhoea, the stools being at first yellow, and afterwards green and 



SYMPTOMS. 821 

acid ; of occasioual voraitiug, of attacks of colicky pain, and sometimes 
of feverishneJis. To sliow how frequent is the occurrence of diarrhci^ii in 
thrush, and to prove also that it is not a necessary accompaniment of the 
disease, as has been supposed by some pei-sons, we will quote the fact men- 
tioned by Dr. Berg, that of 115 cases, in only 29 did the stools retain the 
Dormal yellow color throughout the whole course of the disease; while in 
the remaining 86, green evacuations appeared simultaneously with the in- 
vasion, or supervened at a later period. We may cite also the cases 
reported by MM. Trousseau and Delpech, of which only 14 out of 58 pre- 
sented neither gastric nor intestinal complications. 

The amount of exudation is generally small in this form, and it rarely 
extends behind the soft palate. The duration is usually between four and 
nineteen days, the average being about eight or twelve. The termination 
is almost always favorable. 

Grave Fo7-m. — It is under this form that the disease is most apt to occur 
in public institutions for children, and particularly in foundling hospitals. 
That it sometimes occurs, also, in private practice, will not be doubted, we 
think, by any who will read with care the descriptions of the disease given 
by Underwood, Dewees, and Eberle. We have ourselves met with two 
fatal cases in private practice, which presented all the symptoms described 
by M. Valleix as characterizing those observed by him in the Foundling's 
Hospital at Paris, with the single exception of the ulcerations upon the 
internal malleoli. They were both children of parents who had every 
comfort at their command. One died at the age of four weeks, in con- 
sequence of the attempt to rear it on artificial diet. The other perished 
when six weeks old, apparently from some unhealthy condition of the 
mother's milk, which seems the more probable from the fact that the same 
mother had previously lost two children under precisely similar circum- 
stances; all the children of this person were born vigorous and hearty, and 
did well for a short time, but soon after the birth, the nipples of the mother 
became dreadfully excoriated, the digestive organs of the infant began to 
give way, and death finally occurred with all the symptoms of fully de- 
veloped thrush. We can surmise now, though no examination was made 
at the time, that the cause of the disease was a continuance of colostrum- 
corpuscles in the mother's milk. 

The most important symptoms of the grave form arc the buccal cxuda- 
tioiif various abdominal symptoms, particularly diarrhfca, vomiting, and 
colic, and more or less marked fever. The order of succession of the 
symptoms in severe thrush is not always the same. In most of the cases 
the first symptom observed is, probably, diarrli(ea, which is soon followed 
by fever, and in a few days by the appearance of the false membrane in 
the mouth. In a smaller number of instances the buccal exudation is the 
first symptom observed. The characters of the exudation are much the 
same as those observed in the mild form of the disease, except that the 
membrane is thicker, covers a larger portion of the mouth, and generally 
extends to the pharynx and cx-sophagus. In addition to the plastic deposit, 
there sometimes exist, especially in very bad cases, ulcerations upon the 
roof of the mouth, fra:num linguie, and gums. These are generally few 

21 



322 THRUSH. 

in number, and either confined to the mucous tissue, or they may extend 
to the fibrous texture beneath ; the surface upon which they rest is gen- 
erally softened in consistence ; their edges are irregular, soft, and of a 
whitish or reddish color. The heat of the mouth is not generally in- 
creased, except in very severe cases ; the mouth is moist at first, but after- 
wards becomes very dry, and, from the refusal to suck the finger when it 
is introduced between the lips, and the difficulty with which the acts of 
suckling or feeding are performed, is evidently tender and painful. 

The symptoms depending on the enteritic affection, are tend&rness of 
the abdomen, diarrhoea, vomiting, and fever. The abdomen is usually dis- 
tended by flatulent collections in the bowels, and is more or less painful to 
the touch, particularly in the right iliac fossa and epigastrium, and in 
severe cases over its whole extent. At the same time the child evidently 
suffers from colicky pains, as shown by restlessness, by uneasy, twisting 
movements of the trunk, by kicking of the limbs, and by crying, particu- 
larly just before or at the moment of the evacuations. The appetite is 
usually diminished or entirely lost. The diarrhoea comes on gradually, 
the stools retaining their natural color at first, and being merely thinner 
and more frequent than natural. As the case progresses, they become 
more and more liquid and numerous, and almost invariably of a bright 
green color, and very acid. The green color of the discharges, and their 
highly acid condition, is noticed by all observers. Vomiting occurs in 
many of the cases, but is less frequent than diarrhoea. In some instances 
it is very obstinate and distressing, causing the rejection of whatever ali- 
mentary substances the child may take. Under these circumstances it 
has often been observed to coincide with the presence of a great deal of 
exudation upon the base of the tongue and soft palate, which has been 
supposed to act as its exciting cause. In other instances it is not so fre- 
quent, and as the matters ejected consist of greenish or yellowish bile, 
w^hile, at the same time, the epigastrium is very sensible to pressure, this 
form of vomiting has been thought to depend upon gastritis. 

Fever exists in most cases, from the time that diarrhoea makes its ap- 
pearance, and sometimes at an earlier period. It is at first moderate, but 
as the case goes on, often becomes intense, the pulse rising gradually from 
80 to 90, or 120, 140, and even 160. The lieat of the surface, especially 
of the abdomen, is much increased, and accompanied by dryness. The 
feverish condition of the system is shown also by the restlessness and 
fretting of the child, and often by loud, frequent crying. When the ex- 
udation extends into the pharynx, the cry usually becomes hoarse and 
indistinct. 

There are two other symptoms which occur in the course of thrush, about 
which some discussion has arisen. These are, the appearance of an ery- 
thematous redness about the anus, and upon the buttocks, genitals, and 
upper parts of the thighs, and ulcerations upon the internal malleoli. The 
erythema is stated by M. Valleix to precede the other symptoms in the 
greater number of instances, whilst MM. Trousseau and Delpech deny the 
correctness of the assertion, and observed it to follow the diarrhoea in the 
majority of their cases. It seems to us that the latter authors are correct 



NATURE OF THE DISEASE — DIAGNOSIS. 323 

in ascribing the erythema to the irritation produced by the contact of the 
urine with the skin, which is predisposed, by the cachectic state of the con- 
stitution, to take on intlammation from causes which would not aflect it in 
a healthv subject. The erythema is sometimes followed by papules, vesicles, 
blebs, and ulcerations, all of which probably depend upon the cause just re- 
ferred to. The malleolar ulcerations are ascribed to the friction of the 
ankles against each other, a cause sufficient to produce such an eftect in a 
broken-down, diseased constitution, though iusutHcient in a healthy one. 
We may mention that we have seen the erythema frequently in private 
practice, but never the malleolar ulcerations. 

During the acute period of the disease, the strength of the child is not 
much diminished, but as the case approaches its termination, if no favor- 
able change takes place, the patient becomes weak and exhausted ; the 
face assumes a pale and sallow look ; the features are sharp and defined, 
and the eyes dull and surrounded by bluish circles. At the same time 
the whole body liecomes emaciated, the skin loses its elasticity, and hangs 
in folds or wrinkles upon the limbs, and the surface assumes a dark and 
dingy hue. As the fatal termination approaches, all restlessness ceases, 
and the child lies profoundly still, or only moves the mouth from time 
to time, or utters a faint cry ; the diarrhcea diminishes, and the vomiting 
generally ceases ; the pulse becomes very rapid and weak, the extremities 
cold, and death occurs in the midst of profound quiet, or after a few slight 
convulsive movements. The duration of this form of the disease is very 
uncertain. It is often less than that of the mild form, since many chil- 
dren die in the firet five days after the appearance of the exudation. In 
other cases it is much longer, from a few weeks to two months. Relapses 
are not uncommon. 

Before closing our remarks upon the symptoms, it is proper to state that 
the disease sometimes occurs at the termination of acute local affections, as 
pneumonia, bronchitis, or pleurisy, under which circumstances there will 
be, in addition to the symptoms peculiar to thrush, those of the malady 
which preceded it. 

Nature of the Disease. — Repeated microscopic examinations have 
so uniformly c-onfirmed the statements of Gruby and Berg, that it is no 
longer doubtful that a peculiar parasite, oidium albicans, is a constant ele- 
ment in the exudation of thrush. It is, however, far from being so well 
determined what relation this grow th bears to the disease ; since, while one 
class of authorities consider it the essential and sole cause of the other local 
and general symptoms, another regard it merely as an epiphenomenon, the 
spores of the parasite finding a suitable nidus for development on the al- 
ready diseased mucous membrane. Fortunately, the solution of this ques- 
tion is of no \ery great practical importance, as the causes of the disease 
are well ascertained, and its prophylactic and curative treatment will not 
be affected by the view entertained. 

Diagnosis. — The diagnosis of thrush is rarely difficult. Aphthie dif- 
fer from it in their vesicular nature during the formative stage, in the 
ulcerations which follow the vesick^s, and in the absence of false mem- 
branes. From ulcero-membranous stomatitis it may be distinguished, 



324: THRUSH. 

by the formation in that disease of false membrane in layers from the 
beginning ; by the presence of ulcerations ; by the spongy, bleeding state 
of the gums ; by the fetid breath ; by the absence of the abdominal 
symptoms which exist in thrush ; and by the microscopic appearances of 
the deposit. 

Prognosis. — The prognosis must depend, in great measure, upon the 
circumstances under which the disease occurs. In private practice, and 
whenever the patients are suckled by their own mothers, or by healthy 
nurses, it is a mild affection. But in foundling hospitals, on the contrary, 
where the children are mostly brought up by hand, it is one of the most 
fatal maladies to which children are subject. The prognosis varies accord- 
ing to the form of the disease. The mild form is rarely fatal, while the 
grave form is fatal in the great majority of the cases. 

To show the frightful severity of the disease under certain circumstances, 
we may mention that of 140 cases which occurred in the wards of M. 
Baron, at the Foundling's Hospital of Paris, only 29 recovered ; while of 
22 cases observed by M. Valleix, in the same hospital, but 2 recovered 
(Valleix, loc. cit, p. 74). Again, M. Bouchut states that of 42 cases ob- 
served by himself, at the Necker Hospital, 14 were of the idiopathic (mild) 
form, all of which terminated favorably ; and 28 of the grave or sympto- 
matic form, of which 20 died, and 8 left the hospital still laboring under 
the disease. Of the 20 fatal cases, 12 presented the lesions of chronic en- 
tero-colitis, 4 of acute entero-colitis, 8 of pneumonia, and 1 of hydro- 
cephalus. It may be stated, in conclusion, that the danger is greatest, 
in private practice, w^hen the attack occurs in a child fed on artificial 
diet ; when there is reason to suspect an unhealthy state of the nurse's 
milk ; and in proportion to the extent and quantity of the exudation, its 
resistance to treatment, and the severity and obstinacy of the abdominal 
symptoms. 

Treatment. — Prophyladie Treatment. — The most certain means of pre- 
venting thrush are evidently to procure for the child a full, healthy breast 
of milk, to give it a good habitation, to secure for it perfect cleanliness, 
and to attend properly to its clothing. When it is impossible, from any 
cause, to obtain a nurse for the child, the diet ought to be most carefully- 
regulated as to quality,- quantity, and times of administration. Careful 
attention to these points will, and, we doubt not, have, greatly dimin- 
ished the frequency and lessened the severity of the disease in private 
practice. 

General Treatment. — It is clear that the successful management of 
thrush must depend much more upon judicious regulation of the hygiene 
of the child than upon any therapeutical system that can be devised. The 
most frequent cause of the disease is, as we have seen, artificial diet, espe- 
cially one in which milk is sparingly used or excluded, or an unhealthy 
state of the nurse's milk. It is reasonable to conclude, therefore, that at- 
tention to the removal or mitigation of these and other unfavorable hygienic 
conditions, constitutes the most important indication of treatment. 

If a child who has been attacked with thrush is suckled exclusively, the 
milk of the nurse ought to be subjected to chemical and microscopic ex- 



GENERAL TREATMENT — DIET. 325 

amiuatiou ; and should it be found to present unhealtliy characters, another 
Durse ought to be procured as soon jis possible. In all such cases the nurse 
must pay strict attention to her diet, avoiding all articles which she knows 
or suspects to disagree with her, and all very rich dishes. Dewees recom- 
mends that she should abstain from most common vegetables, except rice, 
and from all kinds of liquors, especially the fermented. 

When the disease occurs in a child who is nursed and fed alternately, 
and the remark about to be made applies still more appropriately to one 
fed entirely upon artificial diet, the most important remedy in the case is 
to procui"e a good wet-nurse. This is far better than any medical treatment 
that can be instituted. Often, however, this is impossible, and, under such 
circumstances, the regulation of the diet ought to be attended to with the 
utmost care by the physician himself, who should specify its material, 
quantity, and mode of preparation. 

As we shall be obliged constantly to refer to the proper diet for young 
children in our future articles on diseases of the digestive organs, and in- 
deed all through this work, we think it will be best to make some general 
and extended remarks on the subject here, where we first meet with a dis- 
ease the cause of which is almost always improper food, and the cure of 
which is the abandonment of a faulty, and the substitution of a proper 
aliment. 

In the first place, we wish to repeat the statement already made, that 
the breast gives the only food for infants which can be relied on as the 
correct one. This may seem very much like saying that white is white, 
and red is red, or that two and two do indubitably make four ; indeed, to 
ourselves it seems utterly superfluous, but we have known so many medical 
men, men in authority in the nursery, and such hosts of fathers and mothers, 
who cannot be made to believe this, that we feel compelled to reiterate our 
own individual opinions as strongly as possible. But cases do constantly 
occur in which a young infant must be wholly or in part fed artificially, 
and here we have to recommend some substitute for breast-milk. In this 
city, as.s's milk, which is conceded to be more like human milk than that 
of any other animal, cannot be had, and we are forced to take cow's or 
goat's milk. The latter is not so common as to be readily obtained, and 
practically we are driven to the use of the former. 

In choosing cow's milk, the first thing to be thought of is tlie purity of 
the milk. In small towns and in the country it is very easy to obtain 
fresh pure milk, but in large cities it is often very difficult. Still, with 
due care and diligence, and money, it can generally be done. Our own 
practice has always been to choose a milkman who himself brings milk 
from a farm, or who, at least, employs himself the man who delivers it. 
We never have, and never shall, so long as we can help ourselves, take 
milk from those middlemen who buy it of anybody that may have it to 
sell. Moreover, the person who has charge of the child should always, if 
possible, know the milkman penK>nally, and know exactly where he comes 
from, and what manner of man he may be. An honest farmer or dairyman 
who pastures and feed:* his own cows rm a h(falthy farm is the man to be 
employed to furni-h milk to the poor little baby who has to seek another 



326 THRUSH. 

dairy than his own mother's. If the character of the milkman is not a 
sufficient guarantee, or if, from any accident, the milk has to be changed, 
or if any doubt arises as to its quality, there are some simple methods of 
judging which can be made use of by any person of ordinary intelligence, 
and which will reveal any gross deception on the part of the milk vender. 

A good specimen of cow's milk ought to be slightly acid or neutral ; it 
should contain a certain average proportion of cream, and it should have 
a certain average density. 

These points may be ascertained with sufficient accuracy to guide us in 
our choice or refusal of any sample of milk, in the following mode : Litmus- 
paper turns red when touched by any acid ; a very weak acid will do this. 
If a good specimen of litmus-paper (which can be procured of the apothe- 
cary) turns faintly red when dipped into milk, the milk is properly acid ; 
if turned bright red, the milk is too acid. When no change is produced 
on the litmus-paper, the milk is either neutral (which is sometimes the 
case with healthy milk), or it is alkaline. To determine whether it be 
neutral, turmeric-paper, which is turned brown by alkaline solutions, must 
be used. If the specimen is found to be alkaline in a marked degree, 
either the cow is diseased in all probability, or some alkali has been added 
to the milk. 

It is a curious fact that Dr. Parkes {Manual of Practical Hygiene, 2d 
ed., London, 1866) is almost alone in asserting that healthy cow's milk is 
either faintly acid or neutral. Most authorities assert that it is alkaline. 
In order to determine this matter for ourselves, we tested the milk of 
thirty-one fine cows, fed on the finest pasturage in the neighborhood of this 
city. This was done by taking the milk, just as it was drawn from each 
animal, separately iii the milking-house, and testing at once with the best 
litmus-paper. In all the paper was turned red more or less distinctly. 
Dr. John Ashhurst, of this city, tested for us, with both litmus- and 
turmeric-paper, the milk of nine fine Durham and of four Alderney cows, 
belonging to his father, all on the finest pasturage. He says that in one 
Durham and in one Alderney the milk appears to have been almost 
neutral, and in all the rest more or less acid. In testing the milk of 
another Durham, litmus-paper was reddened, whilst the turmeric was also 
slightly changed, but he supposed the latter change to be due to a greasy 
condition of the milk, owing to the fact that the cow was in the latter 
period of a long lactation. 

To determine the proportion of cream, we may make use of a glass ves- 
sel, made of a section of a cylinder, tall, and not too wide, and graduated 
to inches, with the upper inch divided into hundredths, or a French glass 
divided into centimetres, such as may be found in the shops for the sale 
of chemical apparatus. This is to be filled to the upper mark with milk, 
and put aside for twenty -four hours ; at the end of that time the cream 
will have separated and risen to the top, and its proportion can be read 
off* on the graduated scale. According to Dr. Parkes, the cream should 
be from 4 to 6 per cent. In the milk of Alderney cows, it will reach 30 
to 40 per cent. This seems to us too large a proportion for the use of 
children. 



MODE OF TESTING MILK. 327 

We think, however, that the average of cream given by Dr. Parkes is 
prohahlv rather too low. The Mai^on Biistiquc, a French work of very 
high authority on agriculture, states (tome iii, p. GD that the milk of cows, 
of good race, well kept, furnishes 15 per cent, of cream. The milk sup- 
plied by the milkman employed by one of us gave 14 per cent, of cream 
on one occa^^ion, and 10 at another. The specific gravity of the former 
specimen was found to be 1029. Of three other si>ecimeus bought at 
hazanl, of ditierent dealers, the proportion of cream was 7 per cent., 6 per 
cent., and 14 per cent., respectively. We are disposed to think, therefore, 
that families ought to endeavor to procure milk containing at least 10 per 
cent, of cream. 

We next have to ascertain the density, in order to determine the pro- 
portion of water. The most common adulteration of milk is, of course, 
with water, to increase its quantity, and so augment the profits of the 
salesman. The density or specific gravity, let it be remembered, is no safe 
guide as to the projwrtion of cream. That must be settled in the mode 
just described. But the density gives the proportion of water. The spe- 
cific gravity of good, pure milk is given by Dr. Parkes at 1030.5, or 1026, 
at a tem|>erature of 60° Fahr. We found it in an excellent specimen to 
be 1029. Dr. Parkes found that when, in milk of the specific gravity 
above mentioned, one part of water was added to nine of milk, the specific 
gravity fell to 1027 or 10i^3; when three parts of water were added to 
seven of milk, it fell to 1021 or 1017.5; and when five parts of water to 
five of milk, it fell to 1015. These were the proportions obtained by sev- 
eral experiments. 

We found that the specific gravity of a specimen of excellent milk, as 
ascertained by a hydrometer, was 1028. When to this milk was added 
one-fourth part of water, the specific gravity fell to 1024, and when a half 
had been added it fell to 1020. In another specimen, the specific gravity, 
obtained in the same way, was 1030 at a temperature of 64° Fahr. When 
to this specimen one-half water was added, the specific gravity fell to 1020. 

By these three simple methods of examination, the acidity or alkalinity 
of the milk, the proportion of cream, and the proportion of water, can be 
determined. If the milk is either strongly acid or alkaline, it is not to be 
trusted. If it be strongly acid, it has undergone the acid fermentation, 
and is not fit for use. If it be strongly alkaline, it has either been adulte- 
rated by the addition of an alkali, probably, according to Dr. Parkes, car- 
bonate of soda, to prevent or arrest the lactic acid fermentation, or it may 
have been taken from a diseased cow. Dr. Parkes suggests the latter 
probability in a doubtful way. Dr. J. F. Simon, of Berlin (Animal C/tem- 
iMrfj with Rpfereivre to the Physiology and Patholoyy of 3/a;i, vol. ii, p. 67), 
states, that he analysed milk drawn from the teat of a cow having vaccinia, 
and found it strongly alkaline, and showing with the microscope mucus- 
and pus-corpuscles, while that drawn from a healthy teat had a mild acid 
reaction, and contained no pus- or mucus-corpuscles. He also states (^page 
68), that Herberger has analyzed the milk of cows suflfering from the 
grease, and found it to contain an increased quantity of the alkaline salts. 



328 THRUSH. 

in the first stage ; in the second stage it was thick and viscid, and had, be- 
sides, an unpleasant and putrid taste and smell. In both stages, the pres- 
ence of carbonate of ammonia (an ingredient never before observed in the 
milk) was detected. 

The most common adulteration of milk is with water. The mode of de- 
tecting this, by ascertaining the specific gravity, has already been given. 
Starch is sometimes used to thicken a thin milk. The microscope will de- 
tect this by showing the presence of the starch-granules. 

The mother will often wish to preserve milk, especially in our hot sum- 
mer weather, or for a few days, when on a journey. The best preservative 
in hot weather, for the day, is of course a good ice-chest. Dr. Parkes says 
that when boiled, " the bottle quite filled, and at once corked up and well 
sealed, the milk lessens in bulk, and a vacuum is formed above. It will 
keep thus for some time. A little sugar aids the preservation. If the heat 
is carried in a close vessel to 250° Fahr., the milk is preserved for a very 
long time, even for years ; the butter may separate, but this is of no con- 
sequence ;" or, if a little carbonate of soda and sugar is added, without 
boiling, he says it will keep for ten days or a fortnight. Cooley, in his 
Cyclopcedia of Practical Receipts, states, that the addition of ten to twelve 
grains of carbonate, or bicarbonate of soda, to each pint of milk, will pre- 
serve it for eight or ten days in temperate weather, and adds that this 
addition is harmless, and, indeed, is advantageous to dyspeptic patients. 
The method of boiling, proposed by Dr. Parkes, is the one now so much 
used for preserving fruits fresh. 

Having determined upon the use of cow's milk, we have next to con- 
sider its mode of preparation. 

It should never be given pure to young infants, at least such is our clear 
conviction. We still believe that the old rule, of two parts of water to 
one of milk, is the proper one during the first month. We know that 
some of the more recent writers, and not a few of the physicians of this 
city, now order half w^ater and half milk, and some children do well on 
that proportion ; but we still believe that when the milk is of full average 
richness (containing ten or fifteen per cent, of cream, and having a spe- 
cific gravity of 1028 to 1030), the old rule of two-thirds water is safest. 
And this is certainly true of all sickly children within the month. It is 
easy to increase the proportion afterwards, if the child does not develop as 
it ought ; but the stomach once seriously deranged and overloaded by too 
rich a food, a severe and even a lingering illness may be the penalty the 
child will have to suflfer. 

When the child comes to be one or two months of age, the proportion 
may be increased to one-half, with care ; always, however, returning to the 
first rule, should the child exhibit signs of gastric disturbance, or should 
the stools contain many whitish lumps, consisting of undigested casein. At 
the age of five or six months the proportion may be made two-thirds milk, 
and thus, gradually, the milk may be given pure, though we have seen 
many children who, even at a year of age, did better with a moderate 
dilution than with the pure fluid. 



QUANTITY OF FOOD TO BE TAKEN. 329 

The qiiunfity of food to be given each day is a very important con>;ider- 
ation. and one about which less is usually said than the matter deserves. 
In the first edition of this work, published in 1848, it was stated that, 
from various inquiries and observations, we were led to believe that a 
healthy infjint of two or three weeks old, would receive, from a good nurse, 
and digest well, about a pint of food in twenty-four hours, and that by 
the end of the fii*st, and in the second month, the quantity taken by the 
child increased to a pint and a half or a quart. Some of the data upon 
which these assertions were based were the following : A wonian, attended 
in her confinement by one of us, had a jiint of milk drawn, by the nurse, 
daily from the breasts, in addition to what the child took. On asking the 
nurse how much she supposed the child — a vigorous, hearty boy — took at 
the same time, her reply was that, judging from the frequency and vigor 
with which he nursed, she supposed he took as much as was drawn from 
the breasts. Another patient lost her child at birth, and desiring to go out 
as a wet-nurse, kept up the flow of her milk by using a pnppy. Six weeks 
after her confinement, a good breast-pump was given her, and she was de- 
sired to keep all the milk she could obtain in twenty-four hours. The 
quantity measured exactly a quart. 

It was also stated, in that edition, that careful inquiries were made, in 
regard to this matter, of one of the most experienced and intelligent 
monthly nurses wc ever knew. She was desired to answer accurately the 
two following questions: 

1. How much milk do you think a healthy mother gives to her child 
daily, after the flow is fairly established? 

2. What quantity of nourishment do you give in twenty-four hours, to 
infants you are compelled to feed exclusively? 

The reply to the first question was that she had often drawn more than 
a pint from the breasts in the twenty-four hours, in addition to what a 
healthy child took, and that she had frequently taken as much as three 
pint.s from women who had lost their children. She supposed, therefore, 
that a hearty child would take, during the first two weeks, at least a pint, 
and much more afterwards. 

To the second question she replied, that she usually gave to hearty chil- 
dren of one, two, and three weeks old, a pint of food in twenty-four hours. 

It was stated in the first edition of this work, that, judging from the 
above data, a young infant ought to take at least a pint of nourishment 
in the twenty-four hours. Our experience, since that time, has convinced 
us that, if anything, this estimate is rather too low than too high. Now 
we should say that, in the first ten days after birth, a pint or a little over 
is about the right quantity. After that period a pint and a half to a quart 
is probably the profK*r amount up to the second month. In the second 
and third months many children require a full quart, and some thn^e pints ; 
though, after all, we must be ruled very much by the instinctive wants of 
the individual child. When fed at regular intervals, upon food of the 
proper strength, we do not think children often take more than they need. 

In the first month the child ought to be fed every two hours, if it takes 



330 THRUSH. 

the food well. After the first month, once in three hours, is usually the 
best rule. Feeding the child once in three hours, between six in the morn- 
ing and six in the evening, and twice in the night, would give six meals 
in the twenty-four hours.. If six ounces (a gill and a half) be given each 
time, the child would get thirty-six ounces, which is a little over a quart. 
As the age increases, eight ounces may be given every four hours, which 
would make a quart and a half; and we have met with very few children 
who exceed this, particularly as by this time the food consists of two-thirds 
or three-fourths milk, or even pure milk. It may seem needless to add 
that, unless the child is taking decidedly less than the average stated above, 
it ought not to be in any degree forced or enticed to swallow more than it 
takes willingly. The moment it has had enough, the nurse ought to cease 
to offer any more. 

As this matter of the quantity of artificial food necessary for the devel- 
opment of the child is a very important one, and as it is a point which has 
not been very clearly defined by most writers, we have thought it well to 
lay before our readers the following calculation of what infants may need, 
from the estiniate made by Dr. Parkes as to the amount of food necessary 
for adults. 

According to that author, an adult of average size and activity will, 
under conditions of moderate exertion, take in twenty-four hours from 
TT^gth to 2"V^^^ ^^ ^^® 0^^ weight in solid and liquid food. The relative 
proportion of the so-called solid and liquid food varies greatly, but is 
usually about 40 oz. avoirdupois of the former, and 60 oz. of water. As, 
however, all the so-called solid food — bread, meat, etc. — contains a certain 
amount of water, the actual average amount of water-free food taken by 
an adult, weighing 150 lbs., is 23 oz., or jl-^ih. of the weight of the body ; 
and the amount of water about 75 oz. Or, in other words, every pound 
weight of the body receives about 0.15 oz. of water-free food and 0.5 oz. 
of water in twenty-four hours. This water-free food is composed as follows, 
according to Moleschott : 

oz. avoirdupois = 437.5 gr. 

Albuminous substances, . . . 4.587 

Fatty " 2 964 

Carbohydrates, 14.257 

Salts (of all kinds), . . . .10.58 

22.866 

On the basis of these calculations, an infant at birth, the average weight 
being 7 lbs., would require 1.05 oz. of water-free food ; and a child weigh- 
ing 20 lbs., which is probably the average weight of healthy children of 
five to six months old, would require 3 oz. 

Assuming the total solid of cow's milk to be 10 per cent., which is rather 
less than the average as given by Becquerel and Kodier (see composition of 
healthy milk), it would require to yield an ounce of water-free food rather 
more than 10 ounces of milk. 

Thus on this supposition (r. e., that the total solids of cow's milk of sp. 



QUANTITY OF FOOD NEEDED BY CHILDREN. 831 

gr. 1026, equal 10 per ceut.) one piut imperial (20 oz.) \\\\\ coutain iu round 
numbers, 

Cju<ein, . 262 grains. 

FaU, . .217 " 

Lactin, . 341 '• 

Salts, . . 43 '♦ 

Total, . . 863 " = very nearly 2 oz. avoirdupois of water-free food. 

According to this, therefore, the infant at birth requires little more than 
i piut imj^rial of unskimmed cow's milk; the child at five or six months 
about 1^ pints imperial. 

It is evident that the pro[X)rtion of fat and water is in great excess in 
this exclusively milk diet ; but these two principles are required in early 
infancy in much larger relative amount than at a later period of life. It 
will also be seen that by diluting the above amounts of cow's milk with 
one to two part^ of water, we obtain, as the proper amount of food for new- 
born infants, from a pint to a pint and a half; and for children about five 
or six months old, from 3 to 4 pints, amounts which correspond closely with 
the results obtained from examination of the quantity of milk secreted by- 
nursing women. 

Some authorities recommend the regular use of lime-water, instead of 
simple water, for the purposes of dilution. We ourselves have not been 
in the habit of using it, except when the rejection of the milk in hard and 
large curds, or the frequent appearance in the stools of small whitish lumps 
of undigested casein, showed a too early and too great coagulation of the 
milk in the stomach. In such cases we always direct lime-water to be added 
to each meal. As to the quantity of this alkali, we will state that Dr. Eus- 
tace Smith (Wasting Diseases of Children, London, 1868, p. 33), directs, 
during the first six weeks of life, that half lime-water and half milk be 
used. Dr. Routh (Infant Feeding, 2d ed., London, p. 397) advises that 
from an ounce to an ounce and a half of lime-water be added to each pint 
of food. The latter is about the proportion we use. In many cases, how- 
ever, our patients do perfectly well without any. 

Besides the dilution with water, sugar must always be added. For- 
merly, the best lump white sugar was always used. Brown sugar has been 
found not to answer well. Of late, experience has shown that sugar of 
milk, which is the natural sugar found in this fluid, is preferable to cane 
sugar. The amount of sugar of milk to be added should always be speci- 
fied by the physician, and not left to the haphazard judgment of the nurse 
or mother, as most persons use too much. A drachm and a half, or about 
a heaped teaspoonful, is the proper proportion for each eight ounces of 
food. 

Many different and more or less complicated preparations of food have 
been recommended by different authorities. We do not think that any of 
the various feculent substances, so much vaunted and adverti.sed for the 
use of the public, are of any value in the early months, a-^ compand with 
milk. Milk must be the basis. It is the really important j)art of the 



332 ^ THRUSH. ^^M 

Dutriment. It matters not greatly what be the feculent substance used, 
we think, if only the milk be good and in sufficient quantity, and the 
feculent material be in small proportion. To depend on amylaceous food 
is usually to sicken, and finally to starve the child. And yet we have 
found by experience that a small quantity of amylaceous material com- 
bined with the milk does render the food more digestible. We think that 
the opinion held by several physicians, that the particles of starch lessen 
the tendency of cow's milk to coagulate into hard large masses, by being 
interposed between the elements of the casein, may be the correct one. At 
all events, experience, as stated above, has led us into the habit of using 
a small quantity. The following preparation was published in our first 
edition, and we have employed it in a great many instances, and have 
found it the best substitute, as a rule, for the natural aliment, that we are 
acquainted with. 

It is made by dissolving a small quantity of prepared gelatin or Eussian 
isinglass ia water, to which is added milk, cream, and a little arrowroot, or 
any other farinaceous substance that may be preferred. The mode of 
preparation and the proportions are as follows : A scruple of gelatin (or 
a piece two inches square of the flat cake in which it is sold) is soaked for 
a short time in cold water, and then boiled ito half a pint of water until 
it dissolves, — about ten or fifteen minutes. To this is added, with constant 
stirring, and just at the termination of the boiling, the milk and arrow- 
root, the latter being previously mixed into a paste with a little cold 
water. After the addition of the milk and arrowroot, and just before the 
removal from the fire, the cream is poured in, and a moderate quantity of 
loaf sugar added. The proportions of milk, cream, and arrowroot must 
depend on the age and digestive power of the child. For a healthy infant 
within the month, we usually direct from three to four ounces of milk, half 
an ounce to an ounce of cream, and a teaspoonful of arrowroot to a half 
pint of water. For older children, the quantity of milk and cream should 
be gradually increased to a half or two-thirds milk, and from one to two 
ounces of cream. We seldom increase the quantity of gelatin or arrow- 
root. 

We have given this food to a great many children during the last 
twenty-five years, as well to those brought up entirely by hand, as those 
partly suckled, or weaned, and can truly state that they have thriven better 
upon it than upon anything else we have employed. In several cases it 
has agreed perfectly well with infants who could not, without vomiting, di- 
arrhoea, and colic, take plain milk and water, cream and water, any kind 
of farinaceous food prepared with water, chicken water, or in fact any 
other food that had been tried. In the cases of sick children, it ought 
sometimes to be made even weaker for awhile than in the proportions first 
mentioned above. 

We have been pleased to find that Dr. Routh (loc. cit, p. 315) quotes, 
with great approval, a food recommended by Dr. Merei for feeble children, 
with bowels previously deranged, which is almost exactly the same as the 
above. Dr. Merei is one of the physicians of the Clinical Hospital for the • 
Diseases of Children, in Manchester, and one who must therefore, have 



CONDENSED MILK. 333 

had a large experience. He first makes a decoction of arrowroot with a 
teaspoouful of arrowroot to three-quarters of a pint of water, this (juantity 
to serve for a whole day's supply. It is stated hy Dr. Kouth, that the 
arrowroot is not given as an aliment, but as a softish substance, to soothe 
mechanically the irritation of the intestinal mucous membrane. " Langen- 
beck, indeed," he says, " believes that in such cases the granules of starch 
intersperse themselves between the particles of casein, and thus in great 
measure prevent the formation of hard, indigestible curds." The mixture 
Dr. Merei gives, is stated to consist of three or four parts of this thin de- 
coction of arrowroot, to one part of new milk, slightly boiled; and to the 
twenty-four hours' amount of food thus prepared, he adds about one or 
two tablespooufuls of cream. Children, it is further stated, will digest well 
from a pint to a pint and a half of this mixture in twenty-four hours, accord- 
ing to their age. As they grow older, he increases the proportion of milk, 
but not of cream. 

This is so much like our own preparation, recommended twenty-five years 
ago, that we feel strengthened in our own conviction as to its utility, par- 
ticularly as the two experiences have occurred so far apart as England and 
America, and to persons who have reached the result by experience as 
well as theory. 

There are other preparations, such as those of Dr. Frankland and Mr. 
Lobb, which may do well in some cases, but they are so complex, and re- 
quire so much time, as to render them almost useless in the nursery. The 
one recommended by Baron Liebig, called Liebig's food, we have used oc- 
casionally, but have been disappointed in its action ; and it, likewise, is so 
difficult of preparation, that we doubt its coming into general use in the 
nursery, where a food, to be well and properly prepared, must be simple. 

Condensed Milk is now a good deal used as a diet for children. It is 
made by evaporating the water from milk placed in open pans or vats, at 
a temperature of from 150° to 175° Fahr. Generally, seventy-five per cent, 
of the original bulk of water is driven off. There are two varieties of the 
preparation, one in which the milk is simply evaporated, so that four pints 
become one pint, without the addition of any preserving substance ; and 
another, in which, after evaporation to the same degree, cane-sugar is 
added. The former will keep from one to four weeks, the latter for 
months or years. The latter is the preparation almost universally used 
for children. It is of a thick, semifluid consistence, is preserved in tin 
cans carefully soldered, and may thus be readily transported. It keeps 
closed, it is said, for years, and, even when a can is opened and kept open, it 
becomes drier or more solid, but does not spoil for some weeks. 

It contains about one-third of its weight of sugar. Dr. Pavy ( TVeathe on 
Food and Dietetics, Phi la. ed., 1874, p. 187) gives the proportion of lactiu 
or sugar of milk in cow's milk as 5.2 per cent. It ap])ears from three 
analyses of condensed milk (^see Pavy, Ion. e?7., p. 194), that the (piantity 
of sugar of milk was 16.50, 12.00, and 17.54 per cent, respectively. In 
the same specimens the amount of cane-sugar was 27.11, 29.59, and 27.06, 
In the different example.*. This would give the whole amount of sugar of 
the two kinds in th^ different specimens 43.61, 41.59, and 44.64. If con- 



334 . THRUSH. 

densed milk be reduced to its original fluidity, by the addition of the 
seventy-five per cent, of water, which had been driven off by evaporation, 
we should have a milk containing considerably less than the five per cent, 
of lactin or sugar of milk, said to exist in ordinary cow's milk, and from 
six to seven per cent, of cane-sugar, of which there is none in the natural 
product. 

This preparation is now used to a considerable extent in this country on 
journeys and voyages, at some of the seaside watering-places in the sum- 
mer, and in some of our cities, where good fresh milk cannot be obtained. 
It is used of very different strengths by different persons. A physician 
who has a large practice in this city, and who uses it constantly in his 
practice, preferring it in many cases to fresh milk, adds six tablespoonfuls 
of boiling water to one heaped teaspoonful of the condensed milk, and 
gives the child as much as it wishes to take. Of course, no sugar is added, 
as the milk is already far sweeter than the natural fluid. This proportion 
makes a milk of a very weak character. Condensed milk, as stated above, 
is reduced in the manufacture in the proportion of four to one. If we add 
six tablespoonfuls of water to one tablespoonful of condensed milk, we 
get a fluid only one-sixth as strong as fresh milk ; or allowing for the 
larger quantity of condensed milk, when the teaspoonful is heaped up, it 
would make a fluid certainly not more than one-fourth the strength of 
fresh milk. This is a singular commentary on the modern practice of 
giving young infants pure cow's milk — a practice insisted upon by some 
recent writers. In one case in our practice, the mother gave her child, 
thirteen months of age, twelve small cans of milk, holding, perhaps, each 
four ounces, in thirteen days. Her practice was to dissolve two heaped 
teaspoonfuls of condensed milk in twelve tablespoonfuls of water, which 
filled an eight-ounce feeding-bottle. This amount of the food was given 
three times between midnight and noon, and five times in the afternoon 
and evening. The child took also half a pound of beef made into half a 
pint of beef tea. It grew well, but was fretful, irritable, and had large, 
copious, pasty, and white stools. The food was reduced by us at once to 
one teaspoonful of condensed milk in six tablespoonfuls of water at each 
feeding. On this diet, the stools improved and the child was much hap- 
pier. The food was then gradually changed to fresh milk, and the child 
is now healthy-looking and cheerful. Another very feeble infant of six 
months old, who, when we first saw it, had had frequent indigestions and 
convulsions on fresh milk, did very well on one heaped teaspoonful of 
condensed milk mixed with four tablespoonfuls of fresh water and two 
tablespoonfuls of lime-water, with ten drops of wine of pepsin after each 
feeding, and a mixture of soda, two and a half grains, sweet tincture of 
rhubarb five drops, and paregoric, two drops three times a day. We tried 
several times fresh milk, but it did not answer. When the child had 
reached the age of fourteen months, it had become reasonably healthy, 
and we ordered some weak beef tea twice a day, and the substitution of 
one tablespoonful of fresh cream in place of one of the tablespoonfuls of 
lime-water. It is now doing well. In another case, one of a pair of twins 
was brought to us at the age of four and a half months — a miserable, 



CONDENSED MILK. 335 

little, pale, feeble, and undergrown infant. Fresh milk had been tried, 
but had caused indigestion and diarrhcva time and again. We ordered 
one teaspoonful of condensed milk to live tablespoonfuls of water and two 
tablespoonfuls of lime-water. On this food the child was much more 
comfortable, and grew slowly. The food was now increased in strength. 
Two heajxxl teaspooufuls of the milk were added to ten tablespoonfuls of 
plain water and two tablespoonfuls of lime-water, and this amount given 
every two or three hours. At the age of eight mouths the child had 
grown somewhat, was in more comfortable health, but was still very small, 
white, and puny. "We now ordered one tablespoonful of cream to be 
substituted for one tablespoonful of the plain water, in the above prepar- 
ation ; and also two t^iblespoonfuls, twice a day, of a beef tea made by 
pouring four tablesix)oufuls of hot, not boiling, water on one teaspoonful 
of Valentine's meat extract. The child is, at the present time, doing 
well on this food, which is to be changed by slow degrees, if possible, to 
fresh milk. The other one of these twins looks well, is well grown, and 
cheerful, on condensed milk, made by adding three teaspooufuls of the 
milk to ten of simple water, and three of lime-water. 

Another patient informed us that condensed milk was ordered for her 
child, in New York, in the proportion of one tablespoonful to twelve table- 
spoonfuls of water, which proportion would represent new milk a third, to 
water, a little more than two-thirds. The child w^as so starved at the end 
of six weeks, that the physician gave the food up in despair, and returned 
to fresh milk. 

Our own conclusion is that condensed milk is not, by any means, so good 
a diet for young children as fresh milk. It certainly is unlike the fluid 
created for the young. It contains a large amount of cane-sugar, which 
does not exist either in woman's or cow's milk, and apparently, from the 
analyses referred to above, it has less sugar of milk than it ought to have. 
But, while this is our opinion in general, we think there are some cases in 
which for a time it is digested better than fresh milk. These cases are 
usually those of delicate infants, who have never been nursed at all, or 
very imperfectly nursed, or who have been made sick by being fed upon 
too strong a diet of fresh milk, or, lastly, who have an idiosyncrasy which 
renders them incapable of digesting the casein of fresh milk, when the 
food is made in any of the usual proportions of water, — a third, half, or 
even two-thirds. We believe that the reason why some children take and 
digest a food made of condensed milk, whilst they reject, or fail to digest 
properly, a diet made of fresh milk, is the result of the very small amount 
of ca.seiu they get in the former. Few medical men in this city think of 
diluting fresh cow's milk more than one-half for infants of two and three 
months old and upwards, and not a few insist upon giving it pure or with 
only a third of water. Yet, when we use one teas|K)onful of condensed 
milk in six teaspooufuls of water, we make a very thin diet, for, to reduce 
the ordinary preparation to the strength of fresh milk, we must mix one 
teaspoonful with only three of water. Then, to reduce this representative 
of fresh milk to an ordinary half water and half milk diet, we must add 
four more teaspooufuls of water, when we should have one teaspmjnful of 



336 THRUSH. 

condensed milk to seven of water. But it is quite the custom here, as 
stated above, to mix a heaped teaspoonful of condensed milk with six table- 
spoonfuls of water. So that, even assuming that the heaped teaspoonful 
represents in fact two ordinary teaspoonfuls of condensed milk, which is 
not quite the fact, we should have a preparation equal to one part of new 
milk to a little more than two parts of water, or about a third milk. 
In view of this fact we may properly ask, on what does the child live? It 
must be that it lives in some measure upon the cane-sugar which has been 
added to the milk to •preserve it, and that it digests the thin diet better 
than ordinary fresh milk diet, simply because it is so deficient in casein. 

The question as to whether condensed milk can safely be relied upon as 
a permanent food for infants and young children, is one that cannot yet 
be authoritatively answered. We do not believe in it, except as a measure 
of necessity, where good, pure, and fresh milk cannot be obtained, or where 
a fair and careful trial demonstrates that the condensed milk diet suits best. 
But, even in these latter cases, we always get back at as early a period as 
possible to the fresh milk. 

Dr. Edward Smith {Foods, New York, 1873, p. 323) says: "This prep- 
aration has been recommended as a food for infants, and it is much liked 
by them ; but it is an error to assume that a given quantity when dissolved 
in water will yield new milk or be as useful as new milk in feeding infants 
and young children, and it should never be used as a substitute in such 
cases whenever new milk can be obtained." 

At page 325 he says again : " Without explaining the medical aspect of 
the question (which would be out of place here), I remark that as a food 
the addition of nearly two ounces of sugar to the pint of cow's milk greatly 
lessens its nutritive value, and induces a tendency to starvation of the 
muscle-forming element. Thus, whilst in natural cow's milk the propor- 
tion of nitrogen (flesh-forming) to carbon (fat-forming) is 1 to 12, in the 
preserved milk it is not much more than one-half, or about 1 to 20. If 
the object were to feed an animal for the market it would be obtained by 
this method, but if to make infants into strong muscular men and women, 
the proportion which nature has provided must be supplied." 

Dr. Smith gives also the views of Dr. Daly (Lond. Lancet, Nov. 2, 1872), 
who, while noting the fact that condensed milk is much liked by children, 
and that those who are fed upon it grow fat and look very well, yet gives 
it as the result of his experience that they have not the same degree of re- 
sistance and vital power as those who are fed on cow's milk, but sink much 
more quickly and dangerously under an attack of diarrhoea or any other 
acute disease. 

Dr. Arthur V. Meigs, one of the assistant physicians to the Children's 
Hospital of this city, informs us that he has been obliged, in most of the 
cases of cholera infantum, brought to the dispensary during the hot sum- 
mer months, to change the diet of those fed on condensed milk to fresh 
milk, as he has found that they rarely do well on the condensed milk diet. 
His friend and colleague. Dr. Louis Starr, has arrived at the same opinion 
as to the comparative value in this disease of the two kinds of diet. 

There is still another objection to condensed milk which we must refer 



CONDENSED MILK. 837 

to. It is more difficult to detect adulterations iu it than in fresh niilk. 
AVe have already given a simple method bv which any intelligent nnnher 
or hous^ekeeper, can detect a material adulteration oi" fresh milk. Tiiat 
condensed milk is not what it ought to be, at least in some instances, is 
proved by the report of the New York Board of Health for 1870 (see 
Tnx> Lectures on the Morals of Trade, by R. Heber Newton, New York, 
1876, Appendix A\ where it is stated that " the condensed milk is found, 
with few exceptions, to be made of skimmed milk entirely or in part. It 
is thus robbed of its cream, and is therefore deficient in fat (butter). This 
really renders it unfit for the nourishment of children aiid tlie fraud is 
more objectionable than that of diluting the whole with water." The re- 
port adds : " It is a notorious fact that most of the condensed milk com- 
panies regularly send cream to the New York market." We have al- 
ready said that Dr. Edward Smith asserts that " whilst in natural cow's 
railk the proportion of nitrogen (flesh-forming) to carbon (fat-forming) is 
1 to 12, in the preserved milk it is not much more than one half or about 
1 in 20." We suppose that Dr. Smith here refers to the condensed milk 
of the English factories. 

Dr. Thomas King Chambers (Diet in Health and Disease, Philadelphia, 
1875, p, Qo), says of condensed or Swiss milk that *'it certainly is digestible, 
as is shown by the fact of infants brought up by hand upon it growing fat 
and apparently strong, a fact of which most of us have ocular proof. 
Great care should be taken that only the softest water is used for its solu- 
tion, and precautions taken against its adulteration. As it is a recent in- 
veDtion it is pure enough at present, but extensive use will probably teach 
ingenious methods of sophistication." Dr. F. W. Pavy {Treatise on Food 
and Dietetics, Philadelphia, 1874, p. 194), gives no personal opinion as to its 
value, but cites, in a foot-note, Dr. Daly's opinion (already quoted) of it. 

The causes which compel us to resort to artificial food for young chil- 
dren, are, of course, very numerous. Thus, it may be impossible, after 
the death of the mother, to secure a reliable wet-nurse; or the mother's 
supply of milk may be manifestly insufficient ; or again, although the 
quantity is abundant, the milk either disagrees with the child, and causes 
vomiting and diarrhcea, or does not nourish, it properly. In every case, 
therefore, where we have reason to sus[>ect that the mother's milk is of 
improper quality, we should subject it to a careful examination ; and, it 
is needless to add, that whenever a wet-nurse is chosen, a similar examina- 
tion of her milk should invariably be made. 

According to Vernois and Becquerel, who examined the milk of eighty- 
one nursing women, the composition of a healthy woman's milk is as 
follows : 

1000 part** of milk contain — 

Water, f<^0 09 

Sugar, 43 04 

Ca^^ein, 3r».24 

Buttf-r 20.00 

SalU, 1.38 

For practical purpose^, however, it is quite sufficient for the physician 

22 



338 THRUSH. 

to determine the specific gravity, the reaction, the amount of cream, and 
the microscopic appearances of the milk. The first three of these points 
are to be ascertained in the way already directed in the examination of 
cow's milk. The density of the milk should be about 1030 to 1032. The 
amount of cream, as tested by the graduated galactometer, should be at 
least three per cent. In regard to the reaction, our own observations are 
not in accordance with the statements of the majority of authors. Thus, 
according to Vogel (pp. eit., p. 32J, "fresh woman's milk is bluish- white 
or pure white, has a feebly sweetish taste, and alkaline reaction^ In order 
to determine this point, the following observations were made on forty- 
three women in the Philadelphia Hospital : 

The subjects chosen were all in good health, and varied in age from 
nineteen to forty-one years. They were all suckling their own children, 
who were from nine weeks to eighteen months old, and, in three-fourths 
of the instances, in good health and well grown. In a good many cases 
the children had suffered more or less severely from diarrhoea during their 
teething. 

The mode of testing was as follows: A few drachms of milk were first 
expressed from the nipple and rejected ; a couple of drachms more were 
then expressed into a spoon, and tested with litmus- and turmeric-papers. 
In no instance was there the slightest alkaline reaction with the turmeric. 
In one instance only was there an acid reaction, and that a very faint one ; 
while in forty-two of the forty-three cases, in nineteen of which the milk 
was tested twice, on successive days, the reaction was neutral. 

It is necessary, in thus testing the milk, to express it into a spoon, since 
litmus-paper is reddened when applied to the moist nipple. 

It would appear, then, from these observations, that woman's milk can, 
at least, not be regarded as unhealthy on account of having a neutral 
reaction. 

The microscopic examination should determine the quantity and size of 
the fat-globules, and the presence or absence of colostrum-corpuscles. 

The fat-globules, also called milk- globules, which are observed in healthy 
woman's milk, should not be very numerous, and should not vary in size 
more than from the 0.0012 to 0.0020 of an inch in diameter. The fat- 
globules, as present in milk, are invested with a delicate albuminous en- 
velope. If the milk be allowed to stand, and the upper stratum of cream 
which forms be examined, along with the ordinary fat-globules, there will 
be numerous others of much larger size. 

In addition to these fat-globules, there are also found in the milk during 
the first two or three weeks after confinement, a number of granule-cells, 
the so-called " cofosfrw7i-corpuscles." These bodies, which present the ordi- 
nary appearances of granule-cells wherever found, consist of an aggrega- 
tion of minute oil-globules in an albuminous basis ; they vary from 0.003 
to 0.006 of an inch in diameter ; and when examined by transmitted light, 
appear opaque and dark-colored. After the period above mentioned (end 
of the second week), they should diminish rapidly in number, and only 
reappear in case the nursing woman is attacked with any acute febrile af- 
fection. If, therefore, they are found to persist long after the time men- 



TREATMENT OF THE GRAVE FORM. 339 

tioned, or if, having almost disappeared, they return in numbers, the milk 
must be regarded as unhealthy. 

After these general remarks on the diet for hand-fed children, which 
we hoi>e will not be thought too tedious, having regard to the great im- 
portance of this subject, not only in thrush, but in all the diseases of child- 
hood, we return to the treatment of the special disease under consideration, 
thrush. 

Few children, with thrush, unless the case be a very mild one, will take 
the full allowance of milk and water we have assumed to be necessary in 
the first weeks after birth. It is clear, however, that if the patient be 
taking only half a pint or a gill a day, it cannot live long on so much less 
than the natural quantity. It ought to take, under these circumstances, 
about two or three tablespoon fuls of food every two or three hours, be- 
tween morning and evening, and once or twice in the night, which would 
amount to from eight to ten ounces in the day ; and this quantity ought 
to be given if the child can be induced, without forcing, to take so much. 
If the usual proportion of two parts water to one of milk, or if the arrow- 
root and gelatin preparation above recommended, should be rejected in 
hard curds, or if masses of undigested curd be found in the stools, it is 
best, for a few days, to dilute Avith three or even four parts of the arrow- 
root solution, or to try for a short time, merely cream and water, one part 
of the former to three, four, or five, of the latter, returning to the mixture 
of cream, milk, and water, as soon as possible. 

In mild cases of the disease, which have been caused by some tempo- 
rarily unhealthy state of the nurse's milk, or, as we have seen it, from the 
occasional use of artificial food to eke out a diminished supply on the part 
of the nurse, after regulating the diet as directed, the use of the following 
mixture, which we have employed for many years past, will often prove 
very successful and tranquillizing : 

R. — Soda? Bicarb., ^ss. 

Tr, Opii Camph., gtt. xl. 

Tr. Khei, gtt. Ixxx. 

Syrup. Simp., f^ij. 

Aq. Menth., f5xiv.— M. 

A teaspoon ful three times a day. 

This dose, continued for several days, or even weeks, will, unless the 
cause continue in force, relieve the pain ami wakefulness, lessen the diar- 
rhoea, and greatly promote the comfort of the child. In connection with 
this, the mouth should be touched, once or twice a day, with a solution of 
nitrate of silver, of one grain to the ounce. 

In the grave form of the disea.se it is necessary, after regulating the 
diet, to employ remedies for the disonlered condition of the alimentary 
canal. These should consist principally of alkalies, astringents, opiates, 
occa.sionally a dose of some laxative substance, nitrate of silver, and the 
external employment of baths, warm cataplasms to the abdomen, and 
sometimes of revulsives. 

The filhiUes usually employed are soda, lime-water, magnesia, chalk, and 
prepared crab's-eyes. Of these we prefer, in most cases, the soda, lime- 



340 THRUSH. 

water, chalk, or crab's-eyes, to be given in the manner which will be rec- 
ommended in the article on entero-colitis. Dewees recommends very 
highly the following formula : 

R. — Magnes. Alb. Ust., gr, xij. 

Tinct. Thebaic, gtt. iij. 

Sacch. Alb., q. s. 

AquEe Font., f^j._M. 

A teaspoonful to be given every two hours nntil the bowels are tranquil. 

He says of it that he has '^long adopted it with entire success." In con- 
junction with the internal use of alkalies and astringents, we would rec- 
ommend the practice pursued by M. Valleix of employing opiate enemata 
and warm poultices containing laudanum, applied upon the abdomen. 
The enemata should consist of one drop of laudanum in a tablespoonful 
of starch-water for young infants, to be used morning and evening. The 
poultices maybe made of Indian. or flaxseed meal, placed between two 
pieces of soft gauze flannel, to be secured around the body by a band, and 
renewed from time to time. 

Purgative remedies are much used in this country in all cases of intes- 
tinal disorder. We believe them to be unnecessary^ and generally inju- 
rious, in thrush, except at the onset, and occasionally through the course 
of the disease, when we may suppose the bowels to contain accumula- 
tions of partially digested aliment, or highly irritating secretions. Under 
these circumstances, and only then, from half a teaspoonful to a teaspoon- 
ful of castor oil, or a teaspoonful of spiced syrup of rhubarb containing 
half a drop of laudanum, may be prescribed, and repeated in case the 
same condition of things should recur. When once the diarrhoea with 
green watery stools is established, we believe all cathartics to be, as a rule, 
injurious. 

Opiates, in moderate quantities, given in combination with alkalies or 
astringents, or used by injection or externally, are of the greatest service at 
all stages of the grave form of the disease. When the diarrhoea is severe 
and obstinate, and particularly when the stools contain mucus or blood, or 
are attended with tenesmic straining, nitrate of silver given internally, or 
used by injection, may be resorted to with very probable benefit. The 
doses and modes of administration will be described under the heads of 
entero-colitis and dysentery. 

Some authors recommend the application of one or two leeches to the 
margin of the anus, or over the left iliac fossa. We think they can rarely 
be proper, and if so, only in vigorous, hearty children, and in cases present- 
ing strongly marked inflammatory symptoms. When the symptoms indi- 
cate great exhaustion, or tend towards a state of collapse, resort must be 
had to stimulants, of which the best are weak brandy and water, or a mix- 
ture of equal parts of wine-whey and arrowroot water. 

Local Treatment. — The local treatment is important in all cases, but 
is of much less consequence than the general treatment, and particularly 
attention to the diet and other hygienic conditions of the patient. Topi- 
cal remedies undoubtedly have the effect, however, in some instances, of 



LOCAL TREATMENT. 341 

arresting the progress of the exudation, and liastening the resolution of 
the disease of the mouth ; but we have uniformly found, in grave eases, 
that no remedies applied to the mouth had any decided influence upon the 
abdominal disease, which is, after all, the cause of the fatal termination 
in the vast majority of cases. Tiie local treatment ought, therefore, to be 
regardeil as adjuvant only to the general management of the disorder. 

In mild cases the most suitable local treatment, the one recommended 
by Underwood, Dewees, Eberle, and MM. Trousseau and Delpech, and 
that which we have generally employed, is the occasional application to the 
mouth of borax. It may be used mixed with an equal quantity of honey, 
and applied by means of a rag or pencil ; or with an equal quantity or 
two parts of finely powdered white sugar, of which a pinch is to be put 
upon the tongue every two or three hours ; or in solution, in the proportion 
of a dmchm to two ounces of water. The best mode probably is to mix it 
with honey. If this application fail to arrest the deposit of the exudation, 
we may resort to alum in powder or solution, or, better still, to solutions of 
nitrate of silver, or to careful cauterization with the solid nitrate. The 
alum may be used in the same manner as borax, or according to the fol- 
lowed formula, recommended by M. Valleix: 

R. — Aluminis, ....... jrr. xv. 

Mel. Ro>a:», ....... ^ijss. 

Decoct. Hordei, f5iijss. — M. 

In the use of the nitrate of silver, we should resort to a solution of five 
grains to the ounce of water. MM. Trousseau and Delpech, however, rec- 
oramend one of thirty grains to the half ounce, or more frequently cauter- 
ize lightly the whole mucous surface with the solid caustic. 

Solutions of salicylic acid, 10 or 15 grains to the ounce, effected by 
means of glycerin, or solutions of carbolic acid, have also been used by us 
with good results. 

Between the applications of any of the above-mentioned remedies, the 
mouth of the infant ought to be occasionally moistened and cleansed 
with some of the mucilaginous solutions, as gum-water, flax.seed tea, or 
that made from .cassafra,s pith, slippery elm bark, or marsh-mallow root. 

Strict and careful attention must be constantly paid to the state of the 
skin around the anus, and upon the thighs and buttocks. These parts 
ought to be well cleansed, after each evacuation of urine or stool, by gentle 
pressure, and not by rubbing, with a fine sponge dipped into tepid milk and 
water, then drie^I with a .'•oft napkin in the .same manner, and well anointed 
with simple cerate, or, what we find better than anything else, Goulard's 
cerate. These precautions ought to be still more carefully observed if 
erythema has already made its appearance. 



342 



AFFECTIONS OF THE TONSILS. 



ARTICLE VI. 



AFFECTIONS OF THE TONSILS. 



1. Acute Inflammation of the Tonsils. — Tonsillitis. — This pain- 
ful affection (known also as angina or cynanclie tonsillaris), occurs in child- 
hood less frequently, but with the same symptoms as after the age of pu- 
berty. We have occasionally met with severe cases of it in children under 
the age of 5 years. 

Symptoms. — When the attack is sudden, there are marked fever, rest- 
lessness or heaviness, and complaints of severe pain on deglutition. If 
the child be old enough to answer questions, the pain will be found to 
radiate from the fauces towards the ear, and to be increased by opening 
the mouth. Painful enlargement of one or both tonsil glands will be 
found by pressing the finger below the angle of the lower jaw. On ex- 
amining the fauces, there is marked redness of the half arches and poste- 
rior border of the soft palate : the affected tonsil projects from its bed as a 
rounded, deep-red body, which may extend even beyond the median line ; 
and if, as less frequently happens, both tonsils are severely inflamed at the 
same time, they may even meet and entirely occlude the isthmus of the 
fauces. The surface of the gland often presents small yellowish points 
which closely resemble patches of false membrane, although careful in- 
spection will show that they are beneath the mucous membrane, and are 
really only the distended follicles of the gland. Deglutition is so painful, 
especially for liquids such as milk or water, that the little patients will at 
times utterly refuse to swallow. 

Course and Duration. — The disease lasts from 3 to 7 days, and ter- 
minates in different ways. It very rarely proves fatal, and only does so 
by obstructing breathing, and at the same time so seriously interfering with 
nutrition that the child^s strength fails. In most cases the result is favor- 
able, and the termination is either by suppuration or gradual resolution of 
the enlarged gland. When suppuration occurs, the symptoms have gone 
on becoming more and more aggravated until they reach their height, and 
the case seems attended with great danger, when suddenly, after an effort 
at vomiting, or spontaneously, the tonsillar abscess bursts, a gush of pus 
occurs from the mouth, and prompt relief is afforded. Occasionally the 
occurrence of suppuration is marked by a chill, or some decided change in 
the febrile movement. 

More frequently in children, however, the tonsil does not suppurate but 
gradually becomes smaller ; the redness subsides, and the distended folli- 
cles disappear. There is a strong tendency, especially after this latter mode 
of termination, for the tonsil to pass into a state of moderate chronic en- 
largement. 

Diagnosis. — The conditions with which acute tonsillitis in children is 
most apt to be confounded, are diphtheria and scarlatinous angina. 

From diphtheria it may be told by the more acute and sthenic character 
of the symptoms ; by the absence of enlargement of any but the tonsil 



TREATMENT — ANATOMICAL APPEARANCES. 343 

glands, and by the local appearances, particularly the absence of pseudo- 
membranous exudation. 

From the angina of scarlatina it may be distinguished by the less fre- 
quent pulse and lower temperature, but chiefly by the absence of eruption, 
so that in some cases the diagnosis cannot be positively determined until 
the time at which the eruption of scarlatina makes its appearance has 
passed. 

Treatment. — So long as the child is able to swallow, quinia may be 
given in full doses, to diminish the fever, and perhaps diminish the liability 
to suppuration. It may be given combined as follows : 

K- — Quinise Sulph., gr. xviij. 

Tr. Ferri Chloridi, .... gtt. xlviij. 
PoUs^je Chlorjilis, . . . • gr. x.\x. 

Syr. Zingibtris, f^j. 

Aquj^, f5ij. 

Dose: Ft. s<>l. 2 teft5poonfuls 4 times a day, for a child 5 to 7 years old. 

If, however, the inflammation be very acute, suppuration will occur in 
all probability, despite our eflbrts. 

It is almost impossible to make any applications to the throat. That 
which is most readily eflTected, and affords as much relief as any other, is 
the inhalation of steam or vaporized warm lime-water. Warm, slightly 
sedative embrocations may also be applied to the neck. It is doubtful 
whether poultices, or any such applications, hasten suppuration sufiiciently 
to make up for the annoyance they cause the child. Even if the occur- 
rence of suppuration be suspected, it is usually impossible to obtain so full 
a view of the parts as to enable an incision to be made to evacuate the pus. 
As, however, the abscess will discharge spontaneously in nearly all cases, 
it is only when the symptoms of obstruction of the throat are very urgent, 
that it is desirable to in.sist upon such an examination. 

The treatment for the chronic enlargement which sometimes remains 
after an acute tonsillitis, will be considered in the next section. 

2. Chronic Enlargement (Hypertrophy) of the Tonsils — 
Causes. — Tiie tonsils are in young children much more subject to this 
aff^M ti«»n than to acute inflammation. The enlargement may begin during 
the fir.-t year of life, but usually does not become sufficient to attract atten- 
tion until the second or third year. Most frequently it has no connection 
whatever with previous acute inflammation of the part, but is chronic and 
indolent from the l>eginning. It is often observed that several children of 
the same family will .suffer from this condition, and it is in fact associated 
in many cases with rickets or with scrofula. We have, however, observed 
marked and enduring enlargement in children of apparently sound con- 
stitution. According to West, the irritation of the latter period of first 
dentition may be the exciting cau.«e in .«»ome of these ca.ses. 

We have already alluded to the fact that occasionally, especially in some- 
what older children, it h&a been an acute attack of ton.«filliti.s — either sim- 
ple or diphtheritic — which has inducer] the state of chronic enlargement. 

Anatomical Appearances. — Both toufrils usually .«hare in the enlarge- 
ment, though not always to an equal degree. They project into the liauces 



344 AFFECTIONS OF THE TONSILS. 

from either side, forming pale red tumors of rounded form, with a surface 
that may either be smooth and glistening, or rough and irregular from the 
rupture of numerous distended follicles. They impart a sense of elastic 
firmness to the finger when pressed. The exact anatomical condition is in 
part an enlargement of the follicles of the gland, associated with thicken- 
ing of the fibro-cellular stroma. The term hypertrophy, commonly ap- 
plied to this condition, must therefore be regarded as indicating merely 
the increase in size of the gland. 

Symptoms. — There can be no doubt but that many symptoms have been 
attributed to the influence of enlarged tonsils which are in reality depen- 
dent upon entirely difi"erent causes. 

The results which are constantly observed are loud snoring during sleep, 
and suufiling, thick voice. There is also often a tendency to acute catar- 
rhal attacks, during which the enlargement of the tonsils increases, and the 
interference with the breathing and voice is much increased. Indeed, in 
some unusually severe cases the respiration is constantly labored, and the 
child is annoyed by a frequent dry hacking cough. The pressure of the 
enlarged glands upon the mouths of the Eustachian tubes may produce 
tinnitus and hardness of hearing. The most serious results which are, by 
many authors, attributed to enlargement of the tonsils are alterations in 
the nose and upper jaw, and the production of the chicken-breast defor- 
mity of the thorax. In consequence of the obstruction of the nasal pas- 
sages caused by the upward pressure of the soft palate, the form of the 
anterior nares may be somewhat altered and contracted, but we are rather 
inclined to refer the small size of the features and the ill-developed upper 
jaw to the rickety cachexia which is so frequent a cause of enlargement 
of the tonsils. So, too, the narrowing of the isthmus of the fauces must 
tend to make inspiration difficult, and thus to prevent full expansion of 
the chest, but we can hardly imagine that such obstruction could produce 
marked chicken-breasted deformity of the thorax, if it were not for the 
fact that in such patients there is usually a high degree of rickets coex- 
isting. It must be borne in mind that precisely this deformity of the tho- 
rax is frequently met with in cases of rickets where there is no enlarge- 
ment of the tonsils. The condition of these glands and the changes in the 
jaws and chest-walls must then, we think, be regarded as results of a com- 
mon cause. So, too, it is probable that the sudden suffocative attacks which 
have been described as occasionally attending chronic enlargement of the 
tonsils have been spells of laryngismus stridulus, dependent upon rachitic 
disease of the bones of the skull. 

Prognosis. — It will be readily seen, therefore, that although this condi- 
tion of the tonsils is obstinate, and yields slowly, if at all, to treatment, it 
is rarely of itself followed by any serious consequences. In very many 
cases it gradually subsides after the patient reaches puberty, while in others 
treatment is successful in reducing the enlargement. We have, however, 
known it to persist most obstinately for many years, even after partial abla- 
tion and prolonged treatment. 

Treatment. — The frequent association of enlargement of the tonsils 
with a rachitic or strumous diathesis must be borne in mind, and if there 



TREATMENT. 3-45 

is any evideuce of the existence of such a constitutional taint, tlie ap- 
propriate treatment must be adopted. Even where no decided evidence 
can be found, it seems desirable to administer such alterative tonics as the 
i«xlide of iron, or the compound syrup of the phosphates of iron and alka- 
lies. The prolonged use of cod-liver oil, with iron and arsenic, has also 
proved of service. 

Counter-irritation by the daily application of dilute tincture of iodine, 
or compound iodine ointment, behind and below the angle of the jaw, may 
be used, and sometimes appears to favor the reduction of the swelling. 

Local applications to the enlarged glands are of much service in some 
ca.-es, but to do good must be steadily persisted in, in conjunction with 
pi-oper internal remedies. Those which have on the whole appeared most 
useful to us have been Lugol's solution of iodine diluted with two to four 
parts of water, and nitrate of silver in the form of rather strong solution, 
as gr. X to the tiuidounce. 

We have also found it of material service in hastening the reduction of 
the enlargement to whiten the surface of the tonsils once in three or four 
days by a light application of solid lunar caustic. 

Recently, the use of injections of ergot and iodine as a means of causing 
the resolution of enlarged glands has been frequently recommended. We 
had found positive benefit from their employment in cases where the children 
were old enough to permit this little operation to be performed without too 
much alarm. The injections should be made into the substance of the 
bypertrophied tonsil, by means of an ordinary hypodermic syringe ; and may 
be repeated about once a week, or according to the effect produced. The 
amount injected should not exceed a few drops, 3 to 5, and should be in- 
troduced very gently, so as to avoid pain as far as possible. The fluid used 
may be either single solution of iodine diluted with water, or a dilute solu- 
tion of ergotin, 48 to 96 grains to the ounce. 

Careful attention to diet, and particularly to the proper and sufficient 
clothing of the child must be insisted on, so as to avoid, as far as possible, 
the repeated acute attacks of slight tonsillitis which are apt to occur. 
Under the persistent employment of the general and local means above 
recommended, we have usually found that the hypertrophy of the tonsils 
has diminished towards the age of puberty. In some instances, however, 
we must confess that all forms of treatment, general as well as local, have 
proved unavailing. We must then resort to excision of the enlarged 
glands, if the .«ymptonis caused by their presence are sufficiently urgent to 
render it advisable. 

The excision of the tonsil (or rather of the prominent portion of it, for 
the entire gland rarely needs removal; is an operation attended, in skilful 
hands, with little difficulty and no danger. It may be readily performed 
with a Fahnestock's or Physick's tonsillotome, or, as many operators i)rc- 
fer, by raising the gland from its bed with a special kind of forceps, and 
then slicing it off with a bistoury. 

The symptoms which would lead us to advise the early removal of the 
tonsils are frequent irritative cough, much interference with hearing or 
with the tones of the voice, or coexisting rachitic deformity of the chest. 



3^6 



iIMPLE PHARYNGITIS. 



ARTICLE VII. 



SIMPLE OR ERYTHEMATOUS PHARYNGITIS. 



Definition ; Frequency. — Simple pharyngitis consists of an erythem- 
atous inflammation of the pharynx, tonsils, and soft palate, unaccompanied 
by ulceration, deposit of false membrane, or gangrene. It is very frequent 
both as an idiopathic and secondary disease. We constantly meet with it 
in children of all ages during the cool months of the year. 

Causes. — It may occur at all ages, and is equally common in the two 
sexes. It is more frequently a secondary than an idiopathic affection. 
The diseases in the course of which it is most apt to occur are scarlet fever 
and measles, and next, pneumonia and bronchitis. It is often an accom- 
paniment of simple laryngitis. The idiopathic form is most common in 
this city in the late winter and early spring mouths. It is said to prevail 
sometimes in an epidemic form. 

The exciting causes of the disease are not always easily detected. • In 
most instances, however, we believe that exposure to cold is the cause of 
the attack. 

Anatomical Lesions. — In mild cases the alterations of texture ob ■ 
served during life, and in a few instances after death, the patient having 
died of some other disease, consist of greater or less redness, swelling, soft- 
ening, and a rough or granular and sometimes oedematous condition of 
the mucous membrane covering the soft palate, tonsils, and pharynx. 
The uvula and tonsils are generally tumefied, and the crypts of the latter 
filled with mucous or purulent fluid of a yellowish color. In one very 
severe case which proved fatal, MM. Rilliet and Barthez found the ton- 
sils very red, soft, only slightly swelled, and infiltrated with pus; the 
pharynx was covered with a thick layer of bloody mucus ; the mucous 
membrane of the throat was of a dark red color, thickened, and granular, 
but not softened. The submaxillary glands were of a grayish color, en- 
larged and soft. 

Symptoms. — Simple pharyngitis of moderate severity begins with rest- 
lessness, irritability, fever, slight cough, and in some instances, pain in the 
throat, which is complained of by older children, and betrayed in those 
who are very young by the refusal to nurse or take food, because of the 
difficulty of swallowing. The face is generally flushed, sometimes very 
deeply so. Young children are often drowsy, but from irritability and 
fever refuse to sleep except on the lap. The fever is marked by accelera- 
tion of the pulse, which rises to 100, 110, or more in children over five 
years of age, and to 120, 130, or 140 in those under that age, and by un- 
usual warmth or even heat of the skin. At the same time the respiration 
is generally more frequent than natural, but almost always regular ; in 
cases attended with high fever, we have counted the breathing at 42 and 
50. Auscultation reveals pure vesicular murmur or slight sibilant rhon- 
chus. The voice is clear, or, in rather severer cases, obscured and nasal, 
and in some instances, speaking is painful and difficult. Cough is a fre- 



SYMPTOMS. 347 

quent symptom. It has beeu present iu a great majority of the cases ob- 
served by ourselves. Iu some of these it was harsh aud croupal, so that 
the childreu seemed threateued with croup. The croupal souud seldom 
laj?ted over oue night, after which the cough was merely hoarse, aud grad- 
ually became loose towards the termination of the attack. In the remain- 
ing cases it was rare and dry iu the beginning, and more frequent and 
looser as the disease progressed. Pain is a frequent, but far from constant 
symptom at the outlet of the disease. It generally exists during degluti- 
tion. When present it is shown in infants, as stated, by their refusing the 
breast, or nursing only at long intervals, and with difficulty ; while in 
older childreu it is complained of. It is not, however, a constant symp- 
tom, as we have often seen children of one, two, and three yeai*s old, with 
severe angina productive of violent fever, who swallowed fluids and soft 
solids without a sign of pain. Throughout the acute period of the dis- 
ease there is generally considerable thirst; the appetite is diminished or 
entirely suppressed ; the stools are usually natural, or there is slight con- 
stipation. 

The throat should always be examined when there is the least reason to 
suspect that an attack of sickness depends upon inflammation of that part, 
and whenever a child has been seized suddenly with fever, particularly in 
cold weather, and there is nothing more evident by which to explain the 
illness. To examine this part well, the tongue must be strongly depressed 
with the handle of a .«poon, which should be carried back to the base of 
the tongue. This may be done in the youngest infant. 

The appenranees presented by the throat areas follows: The soft palate, 
uvula, tonsils, and generally the pharynx also, are more or less reddened 
and swelled, and the mucous membrane commonly looks rough and gran- 
ular. The fauces are often filled with frothy mucus, and in severe cases 
coated all over with mucous or purulent secretions, which sometimes line 
the inflamed surfaces in such a way as to resemble false membranes. 
They are to be distinguished only by careful examination, and by remov- 
ing a small portion on a pencil or sponge-mop, in order to ascertain their 
real nature. We have seen the mild form of inflammation in a child ten 
days old, in one eight weeks, another three months, and a fourth nine 
months old. 

Dr. Wertheiraer {Jour, fur Kinderkrankheiten, Band xxxii) calls atten- 
tion to a variety of angina, which he calls a'dematous, and which is spe- 
cially characterized by serous infiltration of the submucous tissue of the 
pharynx, the mucous membrane itself being pale and smooth, and soft and 
.nicky to the touch. 

The submaxillary (/lands and neighboring cellular tissue are sometimes 
swollen, in conse^juence of the extension of the inflammation to them. 
This is often evident to the eye, but it is more correctly judged of by the 
touch. At the same time the glands are usually somewhat painful to the 
touch. The* amount of swelling is slight in very mild cases, or there may 
be none at all. In severer cases it is much more considerable. 

The breath is said to be often fetid. We have not met with this char- 
a.rtcT in the simple disease. Expectoration is rarely present. We have 



SIMPLE PHARYNGITIS. 

never noticed it under six years of age. Slight nervous symptoms occur 
in nearly all the cases, consisting, as already stated, of restlessness and 
irritability in mild attacks, and of insomnia or drowsiness, with starting 
and twitching, in those which are more severe. 

The fever generally occurs at first only in the after-part of the day and 
during the night, often becoming intense at that time, with restlessness and 
starting, and subsiding or disappearing entirely towards morning, to recur 
again the next afternoon or evening. Children not unfrequently play 
about all the early part of the day, and are attacked with the symptoms 
just mentioned as night comes on. The disease generally pursues this course 
for three or four days, and then passes away entirely or, if it lasts beyond 
that time, the fever becomes continued, and the attack runs on for seven, 
eight, or ten days. 

In grave cases of simple angina, the disease begins with vomiting, fever, 
and severe nervous symptoms, in the shape of excessive restlessness, or som- 
nolence, and occasionally convulsions. The fever is violent, the pulse being 
very frequent and full, and the skin hot and flushed. The intense heat 
and flushing of the skin, which in sanguine children sometimes affects the 
greater part of the surface of the body, together with the activity of the 
circulation, not unfrequently make the onset of the disease resemble very 
closely that of scarlet fever. Four cases of this kind that have come under 
our notice presented severe nervous symptoms at the invasion. In a girl 
between two and three years old, they consisted of wildness and ecstatic 
expression of the face, and trembling uncertain movements of the limbs, 
which would probably have terminated in convulsions, but for the timely 
interposition of a warm bath. In the three others, general convulsions 
occurred. Two of the subjects in which convulsions took place were be- 
tween five and six years old, and one betweep three and four. In two the 
convulsions occurred at the onset, and in a third on the second day. The 
convulsive movements lasted from ten to twenty minutes, and were fol- 
lowed by somnolence for a few hours in two, and by stupor for a day in 
the third. It should be stated, however, that two of these subjects were 
predisposed by constitution and temperament to spasmodic attacks, as one 
had had a fit previously from a similar cause, and the other two from diffi- 
cult dentition. The third had never suffered from any symptoms of the 
kind, and did not appear predisposed to them. 

The tongue is generally dry and coated with a thick whitish fur in 
grave cases ; the respiration is quick, loud, and nasal ; and the voice gut- 
tural or nasal, and difficult. There is usually extreme thirst, and not unfre- 
quently delirium. The throat is commonly violently inflamed, of a deep- 
red color, and coated over with mucous or purulent secretions. The sub- 
maxillary regions are often swelled, and the deglutition sometimes, though 
not always, difficult. When the disease proves fatal, the different symptoms 
soon reach their height, and death may occur in two or three days. We 
have never, however, known simple pharyngitis to terminate fatally. The 
duration of the grave cases is variable. In the four that we have noted, 
it was between three and eight days. 

,Secondary pharyngitis, which, as has been stated, is a very frequent 



DIAGNOSIS — PROGNOSIS — TREATMENT. 349 

disease, will be treated of iu the articles on the various diseases in the 
course of which it occurs. 

Diagnosis. — The diagnosis of simple pharyngitis is not always without 
difficulty, a^ there are no local symptoms in two-thirds of the cases at the 
invasion, nor in some instances at any period of the attack. The physi- 
cian and attendants, therefore, are often deceived as to the real cause of 
the violent fever which has so suddenly made its appearance, and are dis- 
posed to refer it to any but the true one. 

It has happened to us several times in cases of children attacked with 
simple angina, to suspect pneumonia from the sudden occurrence of fever, 
rapid respiration, slight, dry cough, and the absence of pain iu the throat, 
difficulty of deglutition, or other symptoms, to call our attention to the 
real seat of disease. The diagnosis is to be corrected only bj^ the absence 
of the physical signs of pneumonia, and the consequent necessity of find- 
ing some other cause of the sickness. Angina may be mistaken also for 
indigestion, which is one of the most frequent causes of sudden fever in 
childhood, and is accompanied, like severe angina, by vomiting. The dis- 
tinction between the two is to be made by careful inquiry as to the history 
of the attack, by examination of the matters ejected from the stomach, 
and by inspection of the throat. Severe cases, particularly when ushered 
in by convulsions, may be mistaken for disorder of the nervous system 
dependent upon dentition. The only method of ascertaining the truth is 
again the inspection of the throat. Cases of this kind might also be mis- 
taken for the beginning of scarlet fever. Time only, and the development 
or absence of the symptoms peculiar to the latter disease, could enable us 
to determine the diagnosis. 

The diagnosis between simple and pseudo-membranous pharyngitis will 
be given under the head of dij)htheria. 

Prognosis. — Simple pharj'ngitis of moderate severity is very rarely, if 
ever, a fatal disease. Severe or grave erythematous pharyngitis, on the 
contrary, is often a dangerous malady. The four cases that have come 
under our care, however, all recovered. The unfavorable symptoms in 
such cases are : very violent fever, greatly altered physiognomy, difficult 
respiration, choked and guttural voice, excessive jactitation, delirium, con- 
vulsions, and coma. 

Tr.EATMENT. — Mild cases of simple angina need but little treatment. 
The child ought to l)e confined to a warm room in all cases, and kept in 
bed, or on the lap, if it have fever. The diet must be restricted to milk 
preparations and bread, so long as the fever continues. The therapeutical 
part of the treatment may consist in the use of some mild cvacuaiit, as 
one or two teaspcKjnfuls of castor oil, half a teaspoonful or a teaspoonful 
of magnesia, a small quantity of syrup of rhubarb, or what is all-sufficient 
iu many cases, a simple enema. At the same time we may give, if the 
frequency of pulse, heat of skin, and restk^^sness be considerable, a few 
doees of spirit of nitrous ether, or spiritus Mindereri, alone, or cond)ined 
with from one to four drops of antimonial wine, according to the age. A 
warm bath, if the child is not afraid of it, is an admirable remedy when 
there is much excitement of the circulation ; or a f<x>t-bath, containing 



350 SIMPLE PHARYNGITIS. 

salt or mustard, may be used. Frictions over the throat and neck are 
often very advantageous ; they may be made with hartshorn and sweet oil, 
'with or without the addition of laudanum, or a small quantity of spirit of 
turpentine may be applied upon the skin, so as to produce slight counter- 
irritation. When there is much pain and difficulty of deglutition, the case 
is best treated by the use of nitrate of silver in solution (5 or 10 grains to 
the ounce), or of powdered alum, applied by means of a large throat- 
brush. 

In the severe form of the disease the treatment must be much more active 
than in mild cases. When the fever is very high, and threatening nervous 
symptoms are present, the most speedy means of controlling them is a 
warm bath, continued for fifteen or twenty minutes. If the effects of this 
should be slight or transitory, one or two leeches may be applied behind 
the angles of the jaw, unless the fright and consequent resistance on the 
part of the child are so great as to render their application objectionable. 
Some evacuant dose should be given early in the attack ; it may consist of 
castor oil, magnesia, epsom salts dissolved in lemonade, fluid extract of 
senna, or infusion of senna and manna. The quantity must be sufficient 
to produce several copious stools, and should it fail to operate in three or 
four hours, and the fever continue, it is always well to assist it by means 
of a purgative enema. Two hours after the exhibition of the cathartic, it 
will be proper to resort to small doses of sulphuret of antimony with 
Dover's powder, repeated every hour and a half or two hours, in the man- 
ner recommended in the article on pneumonia. If the secretions into the 
fauces be very abundant and tenacious, so as to impede respiration, the best 
means of getting rid of them is by an emetic of ipecacuanha or alum. If 
they collect again, the throat ought to be cleansed from time to time with 
a small sponge-mop. The inflamed surfaces should be touched two or 
three times a day with a solution of nitrate of silver (from five to ten grains 
to the ounce). The late Dr. C. D. Meigs was in the habit of employing 
with much benefit, in the severe angina of children, whether idiopathic or 
secondary, a wash made according to the following formula : 

R. — Cupri Sulphat., 

Quinise Sulphat., aa, gv. vj. 

Aquge Destillatse, ....... f^j. — M. 

This is applied in the same way as the lunar caustic solution, and we have 
frequently seen it produce most excellent effects. 

The four grave cases observed by ourselves recovered under very simple 
treatment. This consisted in the use of the warm bath, of doses of castor 
oil to move the bowels freely on the first day, and of syrup of rhubarb or 
enemata afterwards to keep them soluble ; of doses of antimonial wine and 
nitre every two hours in such quantity as to avoid sickness ; of mustard 
foot-baths ; stimulating frictions to the outside of the throat ; applications 
of lunar caustic solution to the throat internally, three or four times a day; 
and of rigid diet. In one case the warm bath was used three times in a 
single day, because of the extreme restlessness and heat of the skin, and 
was productive each time of much benefit. 



I 



RETROPHARYNGEAL ABSCESS. 351 

ARTICLE VIII. 

RETROPHARYNGEAL ABSCESS. 

This name is applied to collections of pus formed in the cellular tissue 
between the posterior wall of the pharynx and the vertebral column. 
More frequently the abscess is seated quite high up on the level of the 
glottis, though cases are recorded where it occupied a lower position be- 
hind the oesophagus. 

Causes. — Retropharyngeal abscess occurs idiopathically, or as a sequel 
to some of the specific fevers, or, more frequently, in connection with caries 
of the cervical vertebrie. In one of our own cases, it followed directly 
upon a long sleigh-ride, and was due evidently to the severe chilling of 
the body. Although it cannot be regarded as a disease peculiar to child- 
hood, it is far more frequent in the first ten years of life than during any 
subsequent decade. 

Symptoms. — The early symptoms are irregular and not characteristic. 
In cases where the abscess is connected with caries of the cervical vertebra?, 
the symptoms of this latter condition have preceded. In all cases, how- 
ever, the fii-st indications which lead to a suspicion of the existence of a 
post-pharyngeal abscess are gradually increasing difficulty of swallowing 
and of respiration, which is attended with a loud, stertorous sound, unlike 
the stridulous breathing of croup. There is also marked stiflTness of the 
neck, and the head is rigidly retracted. Any effort to bend the head for- 
ward is followed by urgent increase of the dyspncea, and the same result 
ha.-^ been noticed to follow when the recumbent position was assumed. 
There is an appearance of fulness on one or both sides of the neck behind 
the angle of the lower jaw. Of course the child presents a high degree 
of restlessness and distress, which increases until the interference with 
breathing and swallowing may prove fatal from combined exhaustion and 
asphyxia. In the presence of such symptoms as the above, a careful ex- 
amination of the pharj'nx, both by direct inspection, if possible, and by 
the finger, should immediately be made. The mouth is usually filled 
with mucus, but the swelling of the pcjsterior wall of the pharynx may 
frequently be seen projecting forward so as to constrict the pharyngeal 
space, and obstruct more or less the opening of the glottis. The finger, if 
carried back over the root of the tongue, comes in contact with a rounded 
swelling, which is in the early stages firm and somewhat elastic, and later 
becomes fluctuating. When the abscess is fully formed, the most prom- 
inent point may appear yellowish. Occasionally, in the course of caries 
of the cervical vertebne, perforation of the posterior wall of the |)harynx 
occur* without being precedofl by any such wvere symptoms as have just 
been described as due to post-pharyngeal abscess. We have thus known 
the expectoration of purulent matter with small fragments of carious bone, 
to occur in such cases without any previous symptoms of marked obstruc- 
tion in swallowing or breathing. 



352 



ABSCESS. 



Diagnosis. — The recognition of this affection is often difficult, and it is 
only by bearing in mind the possibility of its occurrence, and making care- 
ful examination with the finger, that we can avoid overlooking its existence, 
in cases where the symptoms are not clearly pronounced. In all cases, 
therefore, where difficulty in swallowing is superadded to dyspnoea, such 
an examination should be made. The affection with which it is most likely 
to be confounded is membranous croup, but the absence of the peculiar 
croupy cough and stridulous breathing, and the existence of dysphagia, 
retraction of the head, with immobility of the neck, fulness at the angle 
of the lower jaw, and, finally, the detection of the swelling at the back 
part of the throat, will render the diagnosis easy. 

Prognosis. — The termination is always doubtful. When, however, the 
existence of the abscess is early recognized, and it is promptly evacuated so 
soon as fully formed, recovery frequently ensues. Even when connected 
with caries of the vertebrae, the prognosis, although of course unfavorable 
from the nature of the primary disease, is not necessarily fatal. In the case 
already referred to as having followed directly upon long exposure to severe 
cold, the child was very ill, with all the characteristic symptoms of this 
affection, for a week, after which the abscess burst spontaneously, and the 
child recovered. 

Treatment. — The approach of a post-pharyngeal abscess can rarely be 
detected so early as to enable any preventive treatment to be adopted with 
success. Indeed, but little could be expected from the use of mild counter- 
irritants, or absorbent applications to the throat. In older children, if rec- 
ognized before suppuration has occurred, some benefit might be derived 
from the use of one or two leeches to the angles of the jaw, or of a blister 
to the back of the neck. The use of small pieces of ice held in the mouth 
will also be found to afford relief. The main indication, however, is to 
watch for the occurrence of suppuration, and then to make as early an in- 
cision as possible. When the seat of the abscess is high up this may be 
done by an ordinary sharp-pointed bistoury, whose blade is guarded up to 
near the point by being wrapped with sticking-plaster. When the abscess 
is lower down it can sometimes be more safely reached and evacuated by 
a trocar and canula. As the opening should be small, there is danger of 
its closing with a reaccumulation of pus ; and it is therefore advisable, as 
recommended by West, to press with the finger upon the sac of the abscess 
occasionally for a day or two. In cases dependent upon caries of the 
vertebrse, it is better to postpone opening the abscess until urgent symp- 
toms are produced by it. Here also it is necessary to employ the other 
means of treatment suitable for that condition, and especially the use 
of some mechanical contrivance by which the weight of the head can 
be supported, and thus relief be afforded to the cervical spine. During 
the course of the disease every effort must be made to sustain the strength 
of the patient. If the interference with swallowing be extreme, nutritious 
enemata may be used until the abscess can be evacuated. In addition, 
we must use opiates in sufficient amount to quiet the excessive pain and 
restlessness. 



INDIGESTION. 353 



CHAPTER 11. 

DISEASES OF THE STOMACH AND INTESTINES. 
GENERAL REMARKS, 

In our division of these diseases, we shall treat first of Indigestion, using 
this term to signify morbid conditions of the digestive function, which we 
suppose to be the result of functional disorder, or of mild, acute or chronic 
catarrh of the stomach. Under the title of Gastritis we shall describe the 
much more rare and dangerous form of disease, in which there is acute in- 
flammation of one or more of the coats of the stomach, and which is sel- 
dom met with except as the consequence of the application of some direct 
irritant to the organ. 

We shall then describe Simple Diarrhoea, in which we suppose the in- 
testinal disorder to be either merely functional, or one of slight catarrhal 
inflammation of the mucous membrane. Next, under the title of Entero- 
colitis or Inflammatory Diarrhwa, we shall treat of that form of diar- 
rhoea which is now by many writers styled acute or chronic catarrh of 
the intestinal mucous membrane, and the chronic forms of which we be- 
lieve to be of the same nature as the disease designated by most of the 
observers whose experience was gathered in the vast field of the late war, 
chronic diarrhoea. We shall pass on then to Cholera Infantum, limiting 
this term to cases in which the disease is of a true choleraic type ; and, 
lastly, we shall consider Dysentery. We have also added separate arti- 
cles on the diseases of the Caicum and Appendix Vermiformis, and upon 
Intussusception. 



SECTION I. 



FUNCTIONAL DIf«EA8E8 OR MILD CATARRH OF THE STOMACH AND 

INTESTINES. 

ARTICLE L 

INDIGESTION. 

Definition ; Frequency ; Forms.— By the term indigestion, wc mean 
that condition of the stomach in which ita function of digestion is dis- 
turbed or suspendwl, independent of inflammation or other disease of the 
organ, appreciable by our senses; or in which there has been found after 

28 



354 , INDIGESTION. 

death, in the few opportunities that have been met with to make such an 
investigation, the lesions which are now usually designated as mild gas- 
tric catarrh. The only anatomical alterations found in such cases, are 
reddening of the mucous membrane in spots by a fine injection, relaxation 
of its tissue, and the presence of a layer of tough mucus. It is a very fre- 
quent affection during the whole period of childhood, and is one of great 
importance on this account, and from the fact of its laying the constitution 
open, by the debility and cachexia which it produces, to various secondary 
affections. In our description of the disease, we shall distinguish between 
the forms which occur during infancy, and after the completion of the first 
dentition. 

Causes. — The principal causes of indigestion in infants are an un- 
healthy state of the milk of the nurse^ the use of artificial diet, and lastly, 
an impaired condition of the digestive function, which disables the stomach 
from digesting even the most healthful aliment. 

The milk of the nurse may be too old for the child, for it has been found 
that a breast several months old, sometimes, though not always, disagrees 
with a young infant, in consequence, no doubt, of the milk being thicker 
and richer at that time than immediately after parturition. The breast- 
glands may continue to secrete colostrum for weeks or even months after 
parturition, and when this is the case the child is almost sure to suffer from 
indigestion and diarrhoea. The milk may be unwholesome because the 
nurse is in bad health, or because her diet is not properly regulated. That 
the diet of the nurse affects her milk, we have no doubt, though it has 
been denied by some persons. 

We have known several children to suffer from indigestion, attended 
with vomiting, acid secretions, colic, and diarrhoea, in consequence of the 
nurse having indulged in a very rich diet, and particularly in vegetables 
and fruits. We do not mean to assert that all nursing-women should abstain 
from fruits, or even live on a very simple diet, for we have known some 
who could make use of the richest food, and eat abundantly of all kinds 
of vegetables and fruits, without the least injury to the child. But there are 
others who cannot do so without occasioning indigestion in their infants, 
because, probably, their children are unusually susceptible to the action of 
the materials absorbed from that kind of food. Again, it is clearly proved 
by recorded cases and by the opinions of various authorities, that the milk 
of the nurse i& affected by her moral condition. Children have been 
known to suffer greatly, and even to die, from taking the milk of a nurse 
who had just before undergone a fit of violent anger. The depressing 
moral emotions, as anxiety, grief, fear, and despair, are well known to affect 
the milk secretion in such a way as sometimes to occasion indigestion. 

The use of artificial diet for young infants, or as the expression is, 
" bringing up on hand or the bottle," is, we believe, by far the most fre- 
quent cause of indigestion during infancy. Very many children with 
whom this is attempted, die of indigestions, chronic diarrhoea, gastritis, 
entero-colitis, cholera infantum, and thrush. Very few escape frequent 
attacks of one or other of the diseases just named. Much depends, no 
doubt, on the selection and preparation of the food. It may be stated as 



1 



SYMPTOMS. 355 

a well-established fiict, that a diet consisting wholly or in a groat part of 
farinaceous substances, very rarely fiiils to disagree with the child, and to 
produce indigestion and other disorders of the digestive system, which 
often prove fatal ; while one in which cow's or goat's milk enters as the 
principal ingredient, though inferior to the natural aliment, and often pro- 
ductive of indigestion, is tar less injurious than the one before spoken of. 

A third cause of indigestion was stated to be the absence or loss of the 
digestive power of the stomach, independent of the nature of the food. 
This is a condition similar to the dyspepsia of the adult. It may be con- 
genital or may result from causes brought into action after birth. It often 
remains as a consequence of previous indigestions from improper or exces- 
sive feeding. It exists during the invasion, course, and convalescence of 
various diseases. Dentition frequently diminishes or impairs the tone of 
the digestive function, so that the child is often unable, during that pro- 
cess, to digest aliment which had agreed with it perfectly well at other 
times. 

The causes of indigestion after the completion of the first dentition are 
congenital feebleness of the digestive function ; a certain want of power of 
that function, which remains often for years in children reared upon arti- 
ficial diet, and in those who have been debilitated by frequent attacks of 
disease of any kind ; the habitual use of improper diet ; the eating of crude, 
indigestible food ; the process of the second dentition ; the want of due 
exercise in the open air; residence in large cities; and undue exercise of 
the mental faculties in the conduct of the education of the child. 

Symptoms. — We shall describe first the symptoms of indigestion as it 
occurs during infancy, and secondly as it occurs during childhood, or 
after the completion of the first dentition. 

Indigestion during infancy may be advantageously considered under 
two heads: as occasional or accidental, and as habitual. By the former 
we mean that which occui-s in a healthy infant from a transient cause, such 
as repletion or a momentarily unhealthy state of the nurse's milk from 
some imprudence on her part as to diet, from some moral cause, or from 
sickness; and that which depends upon the passing influence of dentition. 
By habitual indigestion, we mean the form of the affection which is long 
continued in consequence of a persistence of the cause. 

The symptoms of occasional or accidental indigestion in infants are : 
paleness and contraction of the face; restlessness and peevishness; moan- 
ing and cr\'ing, or in some ca.ses, screaming; nausea, shown by excessive 
paleness, often by very great languor, and by occasional retching, which 
may either subside without vomiting, or as more fre(iuently happens, ter- 
minate in that act; flatulent distension and hardness of the abdomen, 
especially in the epigastric region, often accompanied with eructations; 
and in many of the cases simple diarrhoea. These symptoms usually 
com^ on soon after nursing freely, or after a very hearty meal of artificial 
food, in a child previously in good health. The attack seldom lasts more 
than a few hours or one or two days. The vomiting which almo-^t always 
takes place, and which relieves the stomach from the offending cause, very 
often accomplishes the cure. 



356 INDIGESTION. 

Habitual indigestion in infants causes a train of symptoms which are 
different from and much more severe than those just described. Of these 
the most important are : frequent attacks of nausea and vomiting, and of 
simple diarrhoea repeated for days, weeks, or months in succession ; pale- 
ness, or some other unhealthy tint of the cutaneous surface ; continual 
restlessness and discomfort, with fretting or crying, particularly in the after 
part of the day and during the evening and night, in place of the natural 
ease and quiet of a healthy infant; constant fits of the most violent scream- 
ing from colic, sometimes lasting for hours ; dull and languid expression of 
the countenance, or else an uneasy, contracted look, like that produced by 
continued suffering; more or less emaciation ; failure of the natural growth 
in stature and size, so that the child is small and puny for its age ; want of 
calorific power, causing the child to suffer unusually from cold, as shown 
by frequent coolness of the hands and feet ; irregular appetite, which makes 
it necessary to tempt by frequent changes of the food, or more or less com- 
plete anorexia; and lastly, the various symptoms that indicate an impover- 
ished state of the blood and bad nutrition. 

In some cases there are added to the above symptoms, or there follow 
as a consequence of the indigestion, those of gastritis or entero-colitis, to be 
hereafter described. Indigestion probably seldom proves fatal in infants, 
except from the occurrence of some inflammatory complication, as for in- 
stance, one of the diseases just named, or acute disease of some other prin- 
cipal organ. 

Indigestion in children who have completed the first dentition may, as 
in the case of infants, be occasional or habitual. Occasional indigestion 
occurs in strong and vigorous, as well as in more delicate subjects. The 
attack generally begins, within a few hours or a day after the child has 
eaten some indigestible substance, with languor and chilliness in older 
children, and with languor and peevishness in those who are younger; 
after which there is headache, pain in the stomach in most of the cases, 
and very often a disposition to somnolence. If the child is attacked with 
vomiting soon after the appearance of these symptoms, and ejects the of- 
fending material, it will often seem perfectly well from that time. If, how- 
ever, this does not take place, fever, sometimes of a violent character, is 
almost certain to make its appearance. The pulse becomes very frequent, 
rising to 120, 130, 160 or over, and being full and resisting; the skin be- 
comes flushed, dry and very hot ; the appearance of the tongue is not gen- 
erally changed early in the attack; there is considerable thirst; the child 
is restless and uneasy, tossing from side to side, or it lies in an uneasy 
sleep, attended with frequent starting and jerking of the limbs or crying 
out; the abdomen is i^atural, or hard and distended over the epigastric 
region. When the symptoms just described make their appearance sud- 
denly, by which we mean in the course of a few hours, in a child two, 
three, four or five years old, after it has eaten some indigestible substance, 
there is reason to fear an attack of convulsions. The probability of the 
occurrence of this accident is great in proportion to the earliuess of the 
child's age, and the impressibility of its nervous system. The attack is 
particularly to be apprehended, and should be carefully guarded against, 



DIAGNOSIS. c57 

whenever the fever is violent, especially if the pulse runs very high, when 
there are urgent complaints of headache, when the restlessness and agita- 
tion are very great, or when there is somnolence, with frequent startings or 
twitchings of the muscles. Convulsions sometimes occur without any pre- 
vious warning, or after such slight signs of disorder as would fail to pro- 
duce uneasiness in the parents or attendants. 

The symptoms produced by occasional indigestion generally continue 
until nature relieves the stomach by vomiting or diarrhcea, or until the 
remedies pro|3er in the case, the most important of which are evacuants, 
have been administered. It happens not unfrequently, that symptoms of 
gastric or intestinal disorder remain for some days after the violence of the 
attack has subsided, and in some instances the disturbance is so great as to 
occasion gjistritis, entero-colitis, or dysentery. 

Habitual ind'njedlon in children who have completed the first dentition, 
is not at all an uncommon affection. It is a condition analogous to, if not 
identical with, the dyspepsia of the adult. The symptoms of this form are 
the following. The general appearance of the child is delicate, as shown 
by a pallid or sallow tint of the skin, instead of the ruddy complexion of 
health, by thinness and want of proper development of the limbs and 
trunk, and by softness and flaccidity of the muscular tissues. There is an 
habitual air of languor and listlessness, with absence of the usual gayety 
and disposition to play natural to the age, and the child often complains 
of being tired. The appetite is feeble or uncertain, being sometimes absent, 
and at other times too great; or it is peculiar, there being a willingness to 
eat of dainties, but a refusal of food of a simple character. The tongue 
presents nothing }>eculiar. It is, however, more frequently somewhat 
furred than clean and natural. The temper is usually irritable and un- 
certain. The child rarely sleeps well ; on the contrary, the nights are 
restless and much disturbed, the sleep being broken and interrupted by 
turning and rolling, by moaning or crying out, and by grinding of the 
teeth. These latter symptoms, together with picking at the nose, which 
is a frequent accompaniment, are almost always referred by the parents 
and nurses to worms, and it is often impossible to convince them to the 
contrary, even though frequent and violent doses of vermifuges have failed 
to show the existence of entozoa. The state of the bowels is uncertain. In 
gome instances they are very much constipated, requiring frequent doses 
of laxatives, or careful regulation of the diet, to keep them soluble; in 
others they are inclined to be loose, and when this happens, the stools are 
often lienteric. In others, again, constipati(jn and diarrhea alternate. 
The alxlomen is usually natural, or somewhat enlarged from flatulent dis- 
tension ; complaints of pain are not uncommon. This form of indigestion, 
like dyspepsia in the adult, is generally a very chronic affection, seldom 
la-ting less than several weeks or months, and sometimes persisting for 
years. 

DiAGNOSLS. — The occasional indigestion of infants is not likely to be 
mistaken for any other complaint. The suddenness of the attack, the 
character and quantity of the matters ejected from the stomach, the ab- 
sence of symptoms indicating the invasion of any other disorder, the short 



358 INDIGESTION. 

duration of the symptoms, and the rapid recovery, all render the true 
nature of the case very clear. That which occurs in older children, on 
the contrary, is not so easy of diagnosis. In many cases the invasion is 
not unlike that of scarlet fever. The vomiting, the rapidity of the pulse, 
the great heat of the skin, and in some cases a certain suffusion of the in- 
tegument dependent on the activity of the circulation, all render the case 
doubtful for some hours, or for a day, after which time the difficulty 
ceases, from the development of the symptoms peculiar to the disorder. 
We believe that not a few cases of simple angina are mistaken for indiges- 
tion, owing to the absence of complaints of sore throat, and the neglect of 
the physician to examine that part. In such cases the vomiting and sud- 
den attack of fever are ascribed, for the want of another mode of explain- 
ing them, to gastric derangement. The diagnosis can be made only by 
examination of the fauces. The diagnosis of indigestion accompanied by 
convulsions, will be considered in the article on the latter affection. 

The habitual indigestion of infants is not likely to be confounded with 
any other disease. The absence of fever, of tenderness of the abdomen on 
pressure, or other acute symptoms, all indicate the dependence of the dis-' 
order on functional distress of the stomach. The same remarks apply to 
this form of the disease occurring in older children. Nevertheless, the 
practitioner should never neglect to make a careful examination, both of 
the physical and rational signs, of all the important organs of the body, as 
it sometimes happens that latent disease of some one of them is the cause 
of the gastric difficulty. 

Prognosis. — The prognosis of occasional indigestion is nearly always 
favorable. It is rarely a dangerous disorder, unless accompanied by con- 
vulsions, or some other sign of violent disturbance of the nervous system. 
Under the latter circumstances, the prognosis should be very cautious, as 
the termination is not unfrequently fatal in consequence of injury done to 
the nervous centres. . It should be recollected also that this form of indi- 
gestion sometimes becomes the exciting cause of inflammation of the stomach 
or intestines, in which event the prognosis will be that of those diseases. 

Habitual indigestion in infants is a serious complaint, and ought always 
to awaken the solicitude both of the physician and parents ; for though 
a simple functional disease of the stomach is probably not often fatal, it is 
exceedingly apt to prove so by the introduction of gastritis, chronic enteritis, 
entero-colitis, or thrush, or by its laying the system open to other diseases, 
and rendering it less able to withstand them should they happen to occur. 
In older children it is not, according to our experience, so dangerous a 
malady. We have never, as yet, seen it terminate fatally. 

Treatment. — The treatment of occasiojial indigestion in infants ought 
to be very simple. The child has generally relieved itself by vomiting 
before the physician is called. If, however, it continues pale and languid, 
with vomiting or retching, after the stomach seems to have been emptied, 
the proper plan is to make use of remedies to calm the irritability of that 
organ. This can almost always be accomplished by giving a teaspoonful 
every ten or fifteen minutes of a mixture of lime-water and milk, consisting 
of one-third milk to two-thirds lime-water, or of equal proportions of each, 



TREATMENT. 359 

or the saaie doses of a mixture cousisting of equal parts of lime-water and 
ciuuamou-water. At the same time a small mustard plaster, weakened 
with wheat flour, or flannels wrung out of hot brandy and water, may be 
applied to the epigastrium, or a warm Indian mush poultice, in a flannel 
bag, laid over the whole abdomen. Should these means fail to relieve the 
sickness, from half a drop to a drop of laudanum, or ten drops of paregoric, 
may be administered, and repeated, if necessary, in two houi-s. The child 
generally recovers its usual health after the sickness has entirely ceased. 
If, however, it remain fretful and uneasy, if it cry much as though in pain, 
it is probable that a jwrtion of aliment has passed, in a partially or wholly 
undigested state, into the intestine. The suspicion will be confirmed if the 
abdcvmen is found, upon palpation and percussion, to be swelled, hard, 
and resonant from flatulent collections in the bowels. Under these cir- 
cumstances, a laxative ought to be given. The best dose is half a tea- 
spoonful or a teaspoonful of castor oil, a teaspoonful of simple or spiced 
syrup of rhubarb, or, if there have been evidences of an acid state of the 
stomach, about a quarter of a teaspoonful of the best magnesia. 

The occasional indigestioii of older children demands a different and 
more energetic treatment. After ascertaining that the child has eaten 
something indigestible, we should inquire whether there has been vom- 
iting. If there has been none, or if only slight, it will be proper to give 
an emetic immediately. The best one under the circumstances is ipecac- 
uanha. This rarely fails to produce a full efl^ect, and does not perturbate 
the system, or irritate the stomach, like tartar emetic. It may be given 
either in powder or syrup. The dose is familiar to every one. If the 
ipecacuanha be not at hand, we may use hive syrup, which is kept in al- 
most every house, or a teaspoonful of powdered alum in honey or molasses, 
t« be repeated, if necessary, in fifteen minutes. Alum is less apt to fail 
than either ipecacuanha or hive syrup. If the child continue unwell after 
the operation of the emetic, which is often the case, and particularly if the 
fever be considerable, a purgative should be given as soon as the stomach 
will bear it. The best dose is castor oil, which is the most speedy and 
least irritating. It may be given in orange-juice, which forms an excellent 
vehicle, or, if the child is old enough, in the froth of beer or porter. A 
dessertspoonful is generally enough. If the oil cannot be taken, we may 
give infusion of senna and manna, the fluid extract of senna mixed with 
spiced syrup of rhubarb, syrup of rhubarb alone, magnesia, to be followed 
by lemonade, salts and magnesia, or the former alone, or, lastly, a seidlitz 
powder. If the fever continue, and the cathartic fail to operate in four or 
six hours, a purgative enema ought to be given to hasten its eflfoct. A 
hath at about 96' or 97° will almost always be found useful in these 
cases. The child should be kept in the bath from eight to twelve or 
fifteen minutes. The only circumstances which form an objection to this 
remedy are the facts of the patient being so irritable, or so fearful of the 
water, as to make it necessary to contend with him in order to succeed in 
using it. When this is the case, it had better not be employed, and spong- 
ing with tepid water and spirit should l>e substituted. If the child com- 



360 INDIGESTION. 

plains of pain io the stomach, the application of a warm mush poultice 
over the epigastrium or whole abdomen will be found of much service. 

When in this form of indigestion the febrile reaction is violent, as it 
often is, and particularly when there are signs of great disturbance of the 
nervous system, consisting of excessive agitation, complaints of severe 
headache, drowsiness, moaning or crying out in the sleep, or twitching 
and jerking of the muscles, the ph5'sician should beware of a convulsive 
attack. In such cases as these, the patient ought to take a purgative dose 
of calomel (from two to three grains), or a dessert-spoonful of castor oil, 
have a warm bath at once, and soon after an injection. The remedies 
ought to be prompt and energetic, for the case is pressing. A convulsion 
is always a dangerous event in childhood, and should be prevented if pos- 
sible. If calomel has been given, a cathartic dose ought to be adminis- 
tered about two hours afterwards, in order to insure an action upon the 
bowels, and to carry the calomel out of the system. After the adminis- 
tration of an evacuant, a full dose of bromide of potassium (ten to fifteen 
grains) should be given, and as this remedy has the very great advantage 
of not arresting the action of the medicines previously administered, it 
may be repeated as frequently as indicated by the nervous symptoms. 
These means rarely fail to afford relief in a few hours. The diet should 
be absolute during the violent stages of the attack, and the usual diet is 
to be resumed only by degrees. The drinks may be plain water or gum- 
water, taken cold. 

It not unfrequently happens that occasional indigestion is followed by 
gastritis or enteritis, or by habitual indigestion lasting for weeks or even 
mouths. These different sequelae must be treated according to the plan 
proper for each. 

The habitual indigestion of both infants and older children, requires a 
very different treatment from the occasional or accidental form. In both 
the indications are nearly the same. The most important are very careful 
regulation of the diet in all its details, the use of tonics and stimulants to 
restore tone and vigor to the digestive function, the employment of reme- 
dies to correct the state of the bowels, whether they be relaxed or consti- 
pated, and attention to securing the child proper exercise, exposure to the 
air, and suitable clothing. 

If the symptoms of the disorder occur in a child at the breast, the milk 
of the nurse should be carefully examined, in order to ascertain whether 
it be good. If found to possess any unhealthy qualities, the nurse ought 
to be changed at once. Attention to this point alone will almost certainly 
cure the child. It needs no other remedy. 

If the patient is fed wholly or in part, it is essential to regulate the diet 
to suit the state of the digestive function. Milk ought in all cases to form 
the basis of the food, unless it has been found by patient trial to be abso- 
lutely repugnant to the stomach. We have often found that infants who 
had been thought quite incapable of digesting cow's milk, could do so 
very readily when it was very much weakened with water. The usual 
proportions for an infant of a few months old, are half and half, or two 
parts milk for one of water. When these are found to disagree, it is well 



TREATMENT. 361 

to try three, or even four or five parts of water to one of milk, and if the 
stomach digest this, as it often will, the proportion of milk may be slowly 
and cautiously increased to the usual standard. If we conclude that milk 
cannot be digested by the child, it is best to try cream. Of this, one part 
to three or four of water may be given. When neither of these can be 
taken, some of the farinaceous substances may be tried ; arrowroot, sago, 
barley, tiipioca, oatmeal, or rice. We are clearly of opinion, however, 
that these articles prepared with water alone, never agree with children 
when they are continued for any considerable length of time. Some in- 
fants? of six or eight months old, it may be remarked, who cannot digest 
more than very small quantities of milk, will take and digest well, very 
delicate broths made of chicken or mutton, or small quantities of the 
lightest meats, as mutton, chicken, or very tender beef, minced up ex- 
tremely fine, and given by teaspoonfuls. 

In cases of this kind we have found a diet consisting of gelatin, milk, 
cream, and arrowroot, prepared in the manner directed in the article 
on thrush, to suit better than anything else. We have met with a 
number of children, whom it was necessary to feed to the amount of a 
pint or a pint and a half a day, in addition to their being nursed occa- 
sionally, who could take neither milk and water, cream and water, milk 
and arrowroot, oatmeal gruel, rice gruel, nor indeed anything that was 
tried, without vomiting, colic, and severe diarrhoea, who digested perfectly 
well and throve admirably upon the preparation alluded to. We have 
now used it during many years, and have recommended it for a great 
many children, and do not h*esitate to say that it agrees with a larger 
number than any diet we have employed or seen employed. 

The diet of older children laboring under chronic weakness of the di- 
gestive function is as important as that of infants. Two chief ends should 
always be borne in mind in selecting it, digestibility and nutritiousness. 
The former is all-important, for without it, the stomach, constantly irri- 
taleil by impro|)er food, has no chance of regaining its tone, while the 
latter is neces-sary in order to sustain the strength of the child, and allow 
it to carry on it« growth. We have generally found it most prudent, and 
often really necessary, to si)ecifS' as to the substances to be given at each 
meal. The morning and evening meal ought to consist of bread and milk, 
mush and milk, or of milk, warm water and sugar (called in this country 
children's or cambric tea), and bread and butter, and nothing else in most 
of the cases. It is sometimes proper to allow a soft-boiled eg<jr, partic- 
ularly if the child be very fond of it. The dinner ought to consist of light 
broths containing rice, with bread or toast, or of the plain meats, as mut- 
ton, beef, chicken, turkey, birds, or fine game. No vegetable ought to be 
allowed in most of the cases except rice, as all others, even the potato, 
are very apt to disagree. We believe that the potato is more digestible 
when roasted than when boiled. If the child require anything between 
breakfast and dinner, it may have what is allowed at breakfast, or dry 
bread and nothing else. There are various articles of diet which should 
be absolutely forbidden, amongst which are h^t and sweet cakes, and hot 
bread of all kinds; sausages, not unfrequently given to children in this 



362 INDIGESTION. 

couutry ; corn-beef, ham, veal, pork, goose, ducks, fish ; all manner of des- 
sert, excepting rice-pudding, or curds-and- whey, often called junket; sweet- 
meats, candies, fruits, except some of our finest summer ones ; and to con- 
clude, everything which long observation and experience have shown to be 
unsuitable to a dyspeptic stomach. 

It is sometimes very difficult to find anything to agree well with the 
child. In one case of a child three years old that came under our obser- 
vation, neither milk, bread, nor meat, could be taken. The casein of milk 
seemed to be absolutely indigestible, as it would be rejected from the 
stomach many hours, or even a day or two, after the milk had been taken, 
in the form of masses of dry, fibrous cheese, of an oblong shape, nearly or 
quite as large as a peachstone. After trying various articles, we found 
that the child digested raw oysters, soda-biscuit, and rennet-whey, and 
upon these articles alone she lived for two weeks, at the end of which time 
she had improved so much as to be able to take the white meat of chicken 
very finely minced. She gradually regained her previous health. 

After regulating the diet, such remedies as tend to invigorate the di- 
gestive functions ought to be prescribed. The most important of these 
are the vegetable and mineral tonics, and mild stimulants. We have 
found quinine, iron, and small quantites of port wine or brandy, to succeed 
better than anything else. To a child under two years old, from a quarter 
to half a grain of quinine, and to one over that age, a grain may be given 
three times a day, and continued for two, three, or four weeks. It is best 
given to young children diff'used, without being dissolved, in a mixture of 
equal parts of syrup of gum and ginger ; 'while to those who are older it 
may be administered in pill. The best preparations of iron are the syrup 
of the iodide, or the pure metallic iron, prepared with hydrogen. Of the 
former, half a drop to one drop for infants, and from two to four drops for 
older children, may be given three times a day ; of the latter a quarter 
of a grain for infants, and half a grain to a grain for those who are above 
that age, may be given three times a day. The metallic iron is best ad- 
ministered in pill, or suspended in syrup of gum arable. When there is 
any suspicion of a scrofulous taint in the child's constitution, or when it is 
disposed to have chronic irritations, excoriations, or ulcerations of the 
nostrils, otorrhoea, or papules or pustules about the eyelids or other parts 
of the body, it is useful to give the iron in compound syrup of sarsaparilla, 
of which half a teaspoonful three time a day is quite enough. Under these 
circumstances, and particularly when the dyspeptic condition is accompa- 
nied with frequent nausea or occasional vomiting, with frontal headache, 
and with constipation, seeming to indicate a disposition to tubercular 
deposit in the system, we have found cod-liver oil the most efficient of all» 
the remedies that we have tried. It has often removed with great rapid- 
ity the dyspeptic symptoms, invigorated the general health, and, in fact, 
restored the patient to health. The dose is from half a teaspoonful to a 
teaspoonful twice or three times a day, at the age of six or eight years. 
It is best taken in a small quantity of malt liquor, or floating on strong 
mint-water, or syrup of ginger. In very young children, and in older 



TREATMENT. 363 

ones also, when the hUter refuse to take it in the ordinary methods, the 
following formula for its administration will be found one of the best : 



01. Jec. Aselli, 


. f5ss. 


P. G. Acaciio, 


. q. s. 


01. Cinnamomi, vel 01. Gaultheriae, 


. gtt. vj. 


Sacch. Alb., 


. q. s. 


Aq. Cinnamomii, 


adf5iij. 


Ft. mistura. 




ose, a dessertspoonful three times a day, after eat 


ing. 



The recent introduction of the use of pepsin in the treatment of dis- 
orders which, like the one under consideration, are characterized by a 
want of digestive power, is a most valuable improvement in their manage- 
ment. It is nearly always perfectly well received by the stomach, and in 
very many cases will enable the child to take and thoroughly digest the 
proper amount of suitable food, which before would have inevitably 
caused evidences of gastric embarrassment, with the rejection of a con- 
siderable part of the meal in an undigested state by vomiting or stool. 

Pepsin may be administered in the form of powder — the best prepara- 
tion of which is that now sold under the name of saccharated pepsin — and 
the proper dose of which for a young child is two or three grains taken 
immediately after meals. Or w^e may use the liquor pepsinse, which is a 
solution of this substance in glycerin and water, acidulated with muriatic 
acid. The proper dose of this latter preparation is from n^^xx to f3ss., 
taken diluted with a little water, also directly after meals. 

The combination of small doses of muriatic acid is unquestionably of 
advantage in increasing the digestive power of the stomach. We have 
thus found the following mixture of much service in the chronic indiges- 
tion of children: 

B.— Acid. Muriatic. Diluti, gtt. xxv. 

Liquor Pe[»sina?, 

Elix. Calisayse, Aa, f^j. — M. 

Dose, from a half tfaspoonful to a teaspoon ful, according to the age of the child. 

In connection with these remedies, a little port wine or brandy, and the 
former is preferable in children over a few years old, on account of the 
pof?j*ibility of their contracting a ta.ste for the brandy, may be allowed 
twice or three timers a day, or at dinner only. To young children, one or 
two tea.«poonful.« of brandy may be given in the course of the day, mixed 
•in water; of the port wine, from a teaspoonful to a tablespoonful, accord- 
ing to the age and strength of the patient, may be repeated morning, noon, 
and night. 

If the bowels are inclined to con.stipation, they .«hould be kept soluble 
by laxative enemata, and by the u.«e of rhubarb or aloes; when relaxed, 
the fre^juency of the di.«charge.'» may be controlled by the cretaceous mix- 
ture, by anodyne enemata given once or twice a day, by the aromatic 



364 SIMPLE DIARRH(EA. 

syrup of galls (to be described under the head of entero-colitis), or by 
some of the astringents in common use. 

In cases where the evidences of a catarrhal state of the mucous mem- 
brane of the stomach and intestine are weaker, we have frequently found 
excellent results to follow the administration of small doses of nitrate of 
silver (gr. -j^^ to gr. j'^) given in solution in thin syrup of acacia. 

In all cases of chronic indigestion in children, it ought to be regarded 
as an essential part of the treatment to secure to the patient a proper 
amount of exercise in the open air. In summer the child should pass 
several hours of every day in the air. It ought, indeed, if the heat of the 
sun can be avoided by proper shade, to pass the whole day in this way. 
In winter it is, of course, impossible to carry this system to the same extent, 
but the child should nevertheless be taken out at least once a day ; this 
may be done in the coldest, and even in damp weather, if sufficient cloth- 
ing be worn. If a child comes back from a walk with warm limbs, and 
with its cheeks in a glow, there is little danger of cold. The quantity of 
clothing must depend on the constitution and idiosyncrasy of the patient. 
Some need twice as much as others. The proper amount is best deter- 
mined by the temperature and coloration of the surface after a walk. 



ARTICLE II. 



SIMPLE DIARRHCEA. 



Under this title we shall describe a mild form of diarrhoea to which 
children are very subject, in which the pathological condition appears to 
be one of mere functional disorder, or of very moderate hypersemia or 
catarrh of the intestinal mucous membrane. We might, indeed, assume 
with some, that the disorder is at all times one of mild catarrh of the 
bowels, but we deem it best, in a practical point of view, to consider it as 
being sometimes one of functional disturbance only, since many observers 
of high authority declare that they meet with cases of even fatal diarrhoea 
in which no anatomical alterations are found after death, and since w'e 
ourselves have met with so many cases in practice which follow a different 
course in symptomatology, duration, and their effects upon the constitution, 
from the form of disease which we shall treat of as entero-colitis or inflam- 
matory diarrhoea. 

Causes. — The causes of the disease during infancy are unfavorable 
hygienic conditions, as the habitation of unwholesome, ill-ventilated, damp, 
and filthy dwellings, or of contracted and crowded quarters of cities and 
towns ; an unhealthy state oj the milk of the nurse ; the use of artificial diet 
at too early an age, especially that of an improper kind ; cold; dentition; 
and lastly, great atmospheric heats. The most important of these are im- 
proper alimentation, by which we mean the use of artificial diet, and par- 



CAUSES. 365 

ticularly one consisting chiefly of farinaceous substances to the exclusion 
of a proper amount of milk, and dentition. For a fuller account of the 
influence of these difterent circumstances on the digestive organs of chil- 
dren, the reader is referred to the remarks on the causes of entero-colitis, 
and to the article on thrush. 

The chief causes of the disease after the first dentition are, according to 
our experience: the habitual use of improper food ; the loss of digestive 
power, which often follows a severe indigestion, or an attack of some acute 
disease ; the debiiifu of constitution, which attends sudden and rapid growth; 
the want of proper exercise and exposure to the air; the predisposition 
which exists in some children from hereditary causes; and the disturbing 
influence of the second dentition. 

The system of indiscriminate diet allowed to children in this country is, 
it seems to us, a fruitful cause of gastric and intestinal complaints. We 
believe that, as a general rule, children over two and three years of age, 
are allowed amongst us to eat of the food prepared for the older members 
of the family. Now, any one who will reflect upon the variety of dishes 
habitually placed upon an American table, ought not to be surprised to 
see children i>ermitted a choice amidst such profusion, pale, thin, delicate, 
exposed to frequent indigestions, attacks of diarrhoea and entero-colitis, to 
gastric fevers, and the host of minor ills attendant upon feeble digestive 
powers. We are acquainted with some families in this city, the children 
of which, from the ^ge of two years, are allowed habitually to breakfast 
upon hot rolls and butter, hot buckwheat cakes, hot Indian cakes, rice 
cakes, sausages, salt fish, ham, or dried beef, and coffee or tea : and to dine 
U|X)n a choice of various meats and a great variety of vegetables, which 
latter they often prefer to the exclusion of meat, and then to make a rich 
dessert of pies, puddings, preserves, or fruits ; and lastly to make an even- 
ing meal of tea and bread and butter, almost always relished, as the term 
is, with preserves, stewed fruit-«, hot cakes of some kind, or with radishes, 
cucumbers, or some similar dish. Add to such meals as the above, the 
eating between whiles of all kinds of candies and comfits, which many 
children here regularly expect in larger or smaller quantity, cakes both 
rich and plain, fruits to excess and at all hours, from soon after breakfast 
to just before going to bed, raisins and almonds, and nuts of various kinds, 
and the wonder is, not that we are a pale, thin, dyspeptic, and anxious- 
looking race of people, compared with Europeans, but that we have any 
health at all, when our children are allowed to make use of the indiscrimi- 
nate and unwholesome diet just described. Such a system undoubtedly 
occasions frequent attacks of the disease under consideration, and unless 
the diet be cbaoged early in the attack, it is very apt to become chronic. 
It has been stated that simple diarrhrea sometimes followed as a ronse- 
quence of indigestion. We have known such a result to occur in children 
previously in fine health, and to continue for several weeks or months. In 
these instances, the disr>rder ap[>ears to depend in good measure on the loss 
of the digestive power of the stomach. This seems proved by the great 
influence which the character of the ffx)d has upon the malady, whirh is 
always aggravated by the use of any articles except those universally ac- 



366 SIMPLE DIARRHCEA. 

knowledged to be the most digestible, and also by the frequent coexistence 
of lientery when the food is not of the lightest kind. 

We have several times met with cases which we could ascribe to no 
other cause than debility and want of power of the digestive organs, de- 
pendent upon too rapid growth. That sudden and rapid growth may pro- 
duce feeble digestion, or, in other words, a dyspeptic state, is, in our 
opinion, proved by the following consideration. It is attended with loss 
of appetite, emaciation, paleness, languor, and weakness, and frequent 
attacks of diarrhoea, or a chronic form of that disorder ; all of which 
symptoms are greatly influenced by the regimen of the child, and are 
most readily removed by attention to that point, and by the use of tonics 
and stimulants. 

The other causes enumerated need but little comment. We will merely 
remark that we have several times observed a predisposition to weakness of 
the digestive organs, transmitted apparently from parent to child. As to 
the influence of the second dentition, we have no doubt that it is a frequent 
cause of the complaint, and we believe that it is too little attended to by 
practitioners. 

Anatomical Appearances. — It has already been stated that w^e look 
upon this disorder as one of purely functional disturbance in many in- 
stances. We are led to take this view by the fact that it is so often unat- 
tended by any of the ordinary signs of inflammatory action, and because 
some very competent observers aflfirm that they hav^ failed to find in a 
certain proportion of cases of fatal diarrhoea, any lesions appreciable to 
tlie senses. Thus, M. Billard says {Mai. des Enfants, p. 392) : " Many 
children at the breast have diarrhoea without enteritis ; they lose color, 
become etiolated, fall into a state of marasmus, and yet at the autopsy not 
a trace of inflammation of the intestines is found." M. Bertin {Mai. des 
Enfants, 2eme ed., p. 574) states that of 57 cases of gastro-intestinal dis- 
ease observed by himself, there were four in which not a trace of inflam- 
mation, or any other appreciable lesion of the digestive tube, could be 
found. MM. Rilliet and Barthez, in their first edition (t. i, p. 491) assert 
that in about every twelve children affected with more or less abundant 
diarrhoea, and in whom we might expect to find colitis, there will be one 
in whom the gastro-intestinal tube will be found in a state of perfect in- 
tegrity. They add that this conclusion is deduced from a comparison of 
nearly three hundred autopsies. We do not find this statement given in 
their second edition, but we do find there (t. i, p. 693) the following para- 
graph : "Quite frequently, especially in early infancy, in cases in which the 
symptoms have pointed to some disease of the gastro-intestinal tube, an 
autopsy reveals no lesion of the solids, or only changes of minimum im- 
portance. The secretions alone are vitiated." One must suppose, there- 
fore, that the class of cases which we describe as simple diarrhoea, are some- 
times quite independent of any anatomical changes in the tissues, recog- 
nizable by our ordinary methods of examination, or that those changes are 
so slight and so evanescent as to disappear after death ; or that they are 
those only of the mildest forms of catarrhal inflammation. It is not un- 
likely, it seems to us, that further and more minute investigation, especially 



ANATOMICAL APPEARANCES — SYMPTOMS. 367 

with the microscope, will reveal tissue-changes which are not discoverable 
by the uuassisted senses. 

When the anatomical changes, constituting the catarrhal state, are found 
in children who presented during life the symptoms of simple diarrha^a, 
they will be such as are described by Niemeyer in the following passage : 
"Catarrh rarely atlects the entire intestinal canal. It is most frequent in 
the large intestine, less so in the ileum, and rarest in the jejunum and duo- 
denum. The anatomical changes left in the cadaver by acute catarrh, are 
sometimes pale, at others dark redness, swelling, relaxation, and friability 
of the mucous membrane, which is sometimes diffuse, at others limited to 
the vicinity of the solitary glands and of Peyer's patches, and a serous in- 
filtration of the submucous tissue. Occasionally, after death, the injection 
has entirely disappeared, and the mucous membrane appears pale and 
bloodless. Swelling of the solitary glands and glands of Peyer is an al- 
most constant appearance ; they distinctly project above the surface of the 
mucous membrane. The mesenteric glands also are usually found hyper- 
semic and somewhat enlarged. The contents of the intestines consist at first 
of plentiful serous fluid, mixed with detached epithelial and young cells, 
subsequently of a cloudy mucus, which is adherent to the wall of the in- 
testine, and contains epithelial structures." 

The best description that we are acquainted with of the anatomical ap- 
pearances found in the intestines in fatal cases of diarrhcea, not in children, 
to be sure, but in adults, is that given by Dr. Woodward in his work on 
Camp Diseases (Philadelphia, 1863). In that work (page 216), under the 
head of simple diarrhoea, he says that this form of diarrhoea is to be re- 
garded as usually the result of irritation of the intestinal mucous mem- 
brane, produced by the ingestion of improper food, or other causes men- 
tioned, and expressing itself in increased secretion throughout the intes- 
tinal tract. The irritation, he goes on to say, may even amount to 
inflammation. Opportunities for post-mortem examination occur but 
rarely. "They reveal little that bears on the nature of the disease, ex- 
cept congestion of the intestinal vessels of variable intensity." At page 
246, will be found a description of the histology of the intestinal lesion in 
chronic diarrhoea, including the changes observed in specimens but moder- 
ately disea.sed, which latter would probably be the analogue of what we 
might expect to find in the simple diarrhoea of children we are now de- 
scribing. We mast refer the reader to the work it,self, as the passage is 
too long to be quoted in full here; but we cannot help thinking that Dr. 
Woodward's de-^criptions would apply also to the changes induced in chil- 
dren by like causes, and leading to similar forms of disease. 

Symi'TOJLS. — We shall describe first the symptoms of simple diarrhcta 
in infants, and afterwards those which characterize the disorder in older 
children. In infants the appearance of the diarrhcea is usually preceded 
or accompanied by slight disturbance of the temper and comfort of the 
child. There is some degree of restlessness, peevishness, and disposition to 
cry; the child sleeps less than usual, and often starts and moans during 
sleep; all of which symptoms are more marked, as is the case indeed in 
nearly all the ailnient.s of chihlren, durin'/ tlu* night. Though the symp- 



368 



SIMPLE DIARRH(EA. 



toms described are observed from time to time, aod particularly during 
the night, they are not always present, as the infant will occasionally 
through the day seem perfectly well and comfortable, with the exception, 
perhaps, of slight paleness and languor, almost always perceptible upon its 
countenance. There is no fever in these cases, or at least nothing more 
than unusual warmth of the hands, feet, and abdomen at night. If a 
marked febrile reaction take place, there would be reason to suspect the 
existence of some degree of entero-colitis. The mouth often becomes, after 
a few days, a little w^armer and less moist than usual ; the tongue is gener- 
ally moist and only slightly coated ; and the appetite is commonly diminished, 
as shown by the child's nursing with less eagerness and at longer intervals 
than before. In very mild cases the stools are at first, and sometimes 
throughout the attack, feculent; the only differences from their ordinary 
characters are that they are more frequent, thinner, more copious than 
usual, and that the odor is changed so as to become acrid and offensive. 
In severe cases, they contain less feculent matter, become yet more fluid 
and sometimes watery, and exhibit small particles of a greenish color scat- 
tered through them ; or the whole of the discharge is of a deep green color, 
and it is intermixed with portions of mucus. In many of the cases, whitish 
lumps, evidently consisting of undigested curd, are observed mixed with 
the other substances upon the napkin. The number of stools varies from 
two, three, or four, to six or eight in the twenty-four hours. The number 
last mentioned is seldom exceeded, so long as the diarrhoea remains simple. 
The abdomen is seldom distended or painful to the touch. The general ap- 
pearance of the child almost always shows the effects of the malady upon 
the constitution after a few days. The countenance becomes paler and 
thinner ; the eyes look some^vhat hollow ; the edges of the orbits are more 
defined, and often present a pale bluish circle; slight emaciation takes 
place, and the flesh of the child becomes softer and more relaxed than be- 
fore the attack. The duration of the disorder is generally short, as it sel- 
dom lasts more than three or four days or a week. It may terminate in 
complete restoration to health, without having exposed the life of the child 
to danger, or, if the causes which gave rise to it continue in action, if the 
child is of delicate constitution or the treatment not correct, and especially 
if this is of too perturbating a character, it is very apt to run into entero- 
colitis and expose the patient to all the dangers of that disease. 

In older children (after the first dentition), the disease is much -less fre- 
quent than in infants, and presents a different train of symptoms. Often 
it is nothing more than a slight disorder of the bowels, amounting to three, 
four, or five stools, thinner and more abundant than usual, accompanied 
by slight colicky pains, and unattended by fever or other signs of sickness, 
which, after continuing one, two, or three days, ceases, and the child re- 
gains its usual health. Some children are particularly liable to these at- 
tacks, and suffer from them every few weeks, or after any indiscretion in 
diet ; whilst in others they are rare, let the diet be what it may. 

There is another form of simple diarrhoea, however, of which we have 
seen a number of cases, much more troublesome than the one just described. 
It occurs in children from two and a half to seven and eight years of age, 



\ 



DIAGNOSIS — PROGNOSIS. 369 

lasts a considerably longer time, and is much less under the control of 
remedial measures. This form of the disease has never, in the cases that 
we have seen, been accompanied by fever, or by any constitutional symp- 
toms rendering it necessary to confine the child either to the bed or house. 
The only symptoms besides the diarrhoea which we have observed, have 
been some degree of paleness and moderate emaciation ; slight weakness, 
shown by an indisposition on the part of the child to play with its usual 
spirit, by an inclination to lie about from time to time through the day on 
the sofa or floor, and by complaints of " being tired ;" irritability of temper 
and peevishness; irregular appetite; picking of the nose; and restless, dis- 
turbed sleep at night, attended with moaning, crying, starting, and grind- 
ing of the teeth ; all of which symptoms generally convince the mother 
that the child is suffering from worms. The abdomen is sometimes slightly 
tumid, but remains natural as to tension, and is not painful on pressure. 
There is no pain except slight colic in some cases. The stools have gener- 
ally numbered from three to five, and in a few cases as many as six or 
eight a day. They are semifluid in consistence, often of a very oflfensive 
odor, and consist usually of feculent matter, which is sometimes clay-col- 
ored, more frequently dark-brown, and, in other instances, deep yellow or 
orange in color. They are often also of a frothy character. In some of 
the cases that we have seen, there was lientery whenever the aliment was 
otherwise than of the lightest and most digestible kind. In all, the diar- 
rhcea was evidently greatly influenced by the diet, showing, it appeared to 
us, a manifest dependence of the malady upon the condition of the stomach, 
which seemed to have lost to a great degree its digestive power. 

The cour.*e of the disease in this form is variable. In some it lasts a few 
weeks, and then, under the influence of diet and remedies, ceases, to recur 
and run the game course after a short period. In others it may last a 
much longer time in spite of all treatment that we attempted. We have 
known it to thus continue between three and four months, with occasional 
slight remissions, brought about apparently by remedies which a day or 
two after would lose their effect. 

DiAf;>'osi8. — The diagnosis of simple diarrhoea will rarely present any 
difficulties, since there is nothing with which it could be confounded, ex- 
cept the dirrrhfpa from tubercular ulceration of the bowels, or entero- 
colitis. From the former it is to be distinguished by the history of the 
case, and by the signs of tuberculosis in other parts of the economy ; from 
the latter, by the absence of signs of inflammatory action. 

Prognosi.s. — The prognosis is favorable so long as the disease remains 
simple. The physician should never forget, however, the disposition which 
is inherent in it to pa.ss into entero-coiitis, nor fail to make the possible oc- 
currence of this transition one element in his prognosis. During infancy 
it is always more serious than after that period, from the feebler jjower of 
resistance on the part of the constitution at that age to disease, which un- 
doubtedly allows this simple afl^ection to prove fatal in some instances, 
probably from the shock to the nervous system. After infancy it is rarely 
a dangeroua disorder, both becau.se of the greater stamina existing at that 

24 



370 SIMPLE DIARRH(EA. 

age, and from the fact that the disposition ,to the extension of disease is 
less strong. 

Treatment. — The prophylactic management of simple diarrhoea is the 
same as that which is proper for entero-colitis, and as that affection will be 
treated of at considerable length in a future article, we must on account of 
our limited space, refer the reader there for information on this point. 

After the disease is established, the treatment must consist first in atten- 
tion to the diet, exercise, and state of the gums of the child. In many- 
cases, careful regulation- of the diet and exercise, and lancing the gums 
w^hen they are much distended and vascular from the pressure of the ad- 
vancing teeth, will suffice to arrest the disorder in a few days, without 
the necessity of resorting to drugs, which ought certainly to be avoided 
whenever it is possible to do so. If the child is at the breast, we must as- 
certain whether the milk of the nurse is good, by inquiry as to its appear- 
ance, specific gravity, reaction, and by examination with the microscope, 
and by reference to her health, diet, temper, etc., all of which circum- 
stances more or less affect the mammary secretion. If we conclude that 
the milk is good, or that it has been disturbed in its healthy properties only 
by a transient cause, the child must be continued at the breast, with the 
precaution, however, of not allowing it to nurse quite so much as usual. 
An infant suffering from any kind of diarrhoea, had better be restricted 
entirely to the breast, unless it be clear that the supply of milk is quite 
insufficient. If we determine that the milk is unhealthy, the nurse must 
either be changed, or the child weaned ; of course the former alternative 
is infinitely preferable if the child is under a year old, or even under 
eighteen months, if it seem to have a rather delicate constitution. 

If the case occiir in a child already weaned, or in one fed partly on 
artificial diet, the regulation of the kind, preparation, and quantity of 
aliment is of the utmost consequence. It ought to consist chiefly of milk 
or cream weakened with water, unless it has been clearly shown by previous 
trial that these articles do not agree with the child. We prefer before any 
kind of diet that v/e have ever employed, or known to be employed, that 
made from cow's milk, cream, arrowroot, and gelatin, in the manner de- 
scribed at page 332. The proportions of the milk, cream, and arrowroot 
must vary with the age and digestive power of the patient. As a general 
principle, during the existence of diarrhoea, or at least in the early stage 
of it, and before the strength has been reduced by the disorder, the propor- 
tions of cream and milk ought to be somewhat less than in health. Not 
only so, but the total quantity of food in the day should be diminished, 
unless the ordinary amount seems to be really necessary for the sustenta- 
tion of the strength. If it be found, after patient trial, that the child will 
not take, or does not digest this kind of food, we may try arrowroot or rice- 
water, with a little cream, or thin gruel or panada, alternated with very 
carefully prepared chicken- or mutton-water. If the child is six or eight 
months old, it often suits well to allow it a piece of juicy beef or a chicken- 
bone to suck, or from one to several teaspoonfuls of meat of chicken or 
mutton minced very fine. 

For older children with a common attack of simple diarrhoea, the diet 



TREATMENT. 371 

should consist for a few days of boiled milk with bread, of gruels made of 
boiled milk and arrowroot, rice-flour, sago, tapioca, or common wheat 
flour, aud of small quantities of light broths. Meats are, for the time, 
improper, aod all vegetables, with the exception of rice, yet worse. 

In the case of infants it is best to recommend a continuation of the 
ordinary exercise, unless the weather be cold and damp. Indeed, in good 
weather, exposure to the air aud proper insolation are more important 
during the existence of this disorder than even during health. The same 
remarks apply to older children, with the exception that they ought not 
to be allowed to fatigue themselves, particularly in warm weather, as this 
tends to aggravate the complaint. 

When the disorder occurs in a teething child, the gums ought always to 
be examined by the physician, and if found swelled, vascular, of a deep 
red color, and hot, with the outline of the advancing tooth perceptible, 
they should be freely incised to the tooth. If, on the contrary, the tooth is 
too deep to be felt, and yet the gum is red and swelled, we would advise 
only a slight and superficial scarification in order to relieve the tensicm. 

The therapeutical management of the disease should be as simple as pos- 
sible. The fewer drugs we can succeed with in the gastro-intestinal com- 
plaints of infants and children, the better. When, however, the diarrhoea 
continues for some days in spite of attention to the points already men- 
tioned, and earlier if the discharges are either large, frequent, very watery, 
or weakening to the child, we must resort to some of the means which have 
been found most useful in checking the inordinate action of the bowels. 
The most important are a careful employment of laxatives, and the use of 
opiates and astriagents. Formerly we generally commenced the treatment 
by the exhibition of a teaspoonful of castor oil, containing from half a 
drop to a drop of laudanum, for young infants, and two drops for older 
children : but of late years we have usually preferred the spiced syrup of 
rhubarb, in a teaspoonful dose, with laudanum, as above recommended. 
Cai«tor oil sometimes purges more than we like ; rhubarb rarely does so. 
These doses given for two evenings in succession have oftentimes sufficed 
to eflTect the cure. Dr. West recommends very highly in cases of simple 
diarrhfpa, in which the evacuations, though watery, are fecal, and contain 
little mucus and no blof>d, small doses of the sulphate of magnesia and 
tincture of rhubarb. His formula at one year of age is as follows: 

B — MHjjne?. Sulphat., r^]. 

Tinct. Rhei f^ij. 

Svr. Zingiber.. .... f;:^]. 

Aqtiee Carui, ....... f3ix. — M. 

Dose, a teaspoonful. 

We often use with excellent effect the sulphate of magnesia, with lauda- 
num, a.s follows: 

B- — Magnw, Sulphat., 3J. 

Tr. Opii Deodorat. gtt. xij. 

Syrup Simp., f^^s. 

Aquse Menth. vel Cinnamom., ..... f^ij*''. — M. 
Dose, at one or two years a tcacpoonful every two or three hour*. For older 
children, the proportion of the magnesia and laudanum should be doubled. 



372 SIMPLE DIARRH(EA. 

If the diarrhoea persists after these means have been used for two or 
three days, or gets rapidly worse, we must resort to some of the astringents. 
The one most commonly employed is the chalk mixture, which is officinal 
in our Pharmacopoeia. A teaspoonful of this is to be given after each loose 
evacuation, or three or four times a day. If the case prove obstinate, it 
will be found useful to add to each dose of the chalk preparation, a small 
quantity of laudanum or paregoric, or some astringent tincture, the best 
of which is the tincture of krameria. When the chalk mixture fails en- 
tirely, powdered crab's-eyes will sometimes succeed ; or we may resort to 
the aromatic syrup of nutgalls. The formulae and doses for both these 
remedies will be found in the article on entero-colitis. If the discharges 
are small and frequent, mixed with mucus and somewhat painful, it will 
be found that small opiate injections (from one to two drops of laudanum 
in a tablespoonful of starch-water for young infants, and from three to six 
drops in double that quantity for older children), or the use of Dover's 
powder in combination with chalk or sugar of lead, will often succeed in 
arresting the disease. One of the most valuable astringents in the bowel 
affections of young children is bismuth, which we are much in the habit 
of giving in the form of subnitrate in doses of from two to five grains, ac- 
cording to the age, from three to six times in the course of twenty-four 
hours. For further and more complete information in regard to astrin- 
gents, we must refer the reader to the article on entero-colitis, where they 
wull be fully discussed. 

The chronic form of simple diarrhoea which we have attempted to de- 
scribe, occurring in children who have completed the first dentition, has 
always proved difficult to manage. From the experience* we have had, we 
believe that the best mode of treating it is by proper regulation of the 
diet, and by the use of tonics and stimulants, and occasionally of opiates. 
We were led to adopt this plan in consequence of having failed entirely 
to control the symptoms by the treatment generally successful in simple 
diarrhoea, and by the opinion which we came at last to form, that the dis- 
ease depended in great part on a loss of the digestive power of the stomach 
and duodenum. The diet must be adapted to the idiosyncrasies of the 
individual ; what we should seek is such a one as will be easily digested 
by the patient, the materials of which shall not appear in the stools, and 
one which does not manifestly increase, if it fail to moderate, the frequency 
of the discharges. The one which we have found to succeed best, consists 
of boiled milk with stale bread for breakfast and tea, and the tenderest 
meats, as very fine beef, mutton, chicken, or birds, with rice, as the only 
vegetable, for dinner. If the child likes flour or rice pap, it may have 
either in place of the bread and milk. If it will take none of these, it 
may have milk, warm water and sugar, with bread ; or well-boiled mush 
with milk, or milk toast. Should it refuse the dinner recommended above, 
we may substitute delicate soup, or some of the milk preparations. Raw 
meat, given in the manner recommended in the article on entero-colitis, 
should also be tried, and will at times prove very beneficial. Between 
meals it ought to be allowed nothing but dry bread. All rich food, dessert, 
fruits, all vegetables except rice, candies and comfits, all kinds of cake and 



TREATMENT. 373 

hot bread, iu fact everything except the articles which we have mentioued, 
or siniihir oues, ought to be rigidly, systematically, and perseveringly for- 
bidden. Until this has been done for many days, or for several weeks, the 
disease has always, according to our experience, obstinately persisted. 

We have already said that we have not found the ordinary remedies for 
simple diarrha^i to exert much etlect upon this form of the disease. On 
the contrary, the treatment for dyspepsia, that is to say, a simple but nu- 
tritious diet, exercise, and the use of tonics and stimulants, has always 
removed it in a longer or shorter time. The tonics which we have em- 
ployed are port wine, quinine, and iron. From a dessert to a tablespoonful 
of port wine was usually given in water three times a day, in connection 
with iron. The preparations of iron used were Vallet's mass, of which 
from half a grain to a grain was given in pill three times a day ; the solu- 
tion of iodide of iron in the dose of first one, and then from two to four 
drops, three times a day, or the solution of the nitrate of iron in the dose 
of from two to five drops, three times a day, in water, continued for one or 
two months. We have sometimes combined with each dose of the solution 
of iron a drop of laudanum, especially if there were pain ; or the opiate 
might be given by injection every evening. The quinine was generally 
administered alone iu the dose of a grain three times a day, for one, two, 
or three weeks. It has not, however, proved so useful as port wine and 
iron. 

Another tonic which we have found very useful in some cases of this 
kind, of late years, is one containing nux vomica and compound tincture 
of gentian, as follows : 

B.— Tr. Nucis Vomic, f^.^s. 

Tr. Gentian Com p., f.^i'j- 

Syrup. Symp., I'^v. 

Aquae, f*ij. — M. 

D<»e, a teagpoonful three times a day after meals, for children of three or four 
yean of age. 

Wine of pepsin, in half teaspoonful doses, three times a day, is also a 
goo<l remedy in such cases, or we may use the powdered saccharated pepsin, 
in doses of two to five grains, taken soon after each meal. 

We have also found in some olwtiuate ca.'ies excellent results to follow 
the administration of nitrate of silver (gr. ^'^th to gr. y'^th) given in solu- 
tion in .syrup of acacia or in pill, according to the age of the child. 

In the case attende<l with all the symptoms usually thought to indicate 
worms, the use of wormsee^l oil was followed by the expulsion of several 
ver}' large lurabricoides. The child did not recover, however, for some 
weeks afterwards, and not until he had taken port wine and quinine for a 
considerable period. In other ca.ses in which the verminous symptoms 
were also strongly marked, and in which the same remedy was given, no 
worms were expelled. 



374 GASTRITIS. 



SECTION II. 

DISEASES OF THE STOMACH AND INTESTINES, ATTENDED WITH 
APPRECIABLE ANATOMICAL LESIONS. 

ARTICLE I. 

GASTRITIS. 

Gastritis, in the sense in which the term was used some ten or twenty- 
years since, viz., to express an individual and special inflammatory disease 
of the stomach, of common occurrence and of supposed great severity and 
importance in childhood, is now well known to be a rare affection. It is 
doubtful, indeed, whether it ever forms a special visceral inflammation, 
except in consequence of the direct application to the organ of some irri- 
tant substance, such as the mineral acids or arsenic, or, as Rilliet and Bar- 
thez found, in a few instances, certain remedial agents, as tartar emetic, 
kermes mineral, and croton oil. In the form of catarrh, acute or chronic, 
of the mucous membrane, on the other hand, it is doubtless one of the 
■most common affections of childhood, constituting an important element in 
^ great many diseases, and especially in the severe forms of indigestion, in 
simple and inflammatory diarrhoea, in cholera infantum, and in many of the 
wasting diseases of childhood, which result from the use of improper arti- 
ficial diet in infants, and of crude and indigestible articles of food in older 
>children. 

We had almost abandoned the plan followed in our former editions, of 
devoting a special chapter to this subject, but on further consideration, 
think it will be best to treat of it separately, since, as stated above, cases 
do occur in practice in which the stomach is the chief, if not the only seat 
of disease, and which can be properly designated and described only under 
the title of gastritis. 

Causes. — It has already been stated that the most violent and typical 
cases of gastritis, as a distinct disease, are the result of the application to 
the organ of some special irritant, as the mineral acids, arsenic, boiling 
water, or of certain remedial. agents, and particularly of tartar emetic, 
iierraes mineral, or croton oil. These latter agents, the drugs just men- 
tioned, cannot produce this effect unless used in large doses, or when con- 
tinued for too long a time. The quantities of the antimonial preparations 
formerly administered, were always thought by us to be dangerously large, 
and we were not at all surprised to find that MM. Rilliet and Barthez, from 
their experience in former years in the Children's Hospital in Paris, cited 
them as one of the causes of acute gastritis. In the Journal fur Kinder- 
kranhheiten, for the years 1859, 1860, and 1861, in the third, fourth, and 



ANATOMICAL APPEARANCES. 375 

fifth aunual reports of the Public Institute for Childreu's Diseases, of 
Vienna, bv the Director, Dr. Luzsiusky, may bo ftuind in the third report 
three cases, in the fourth three cases, and in tlie fifth two cases of gastritis 
caused by the accidental drinking of concentrated lye. 

The milder forms of gastritis are vastly more common than the ones 
above referred to. They are generally associated with disturbances of the 
intestinal tube also, and constitute by far the majority of the cases which 
come under the observation of the physician. They are caused very gen- 
erally by improper alimentation ; by the same causes, indeed, as those 
which determine indigestion. In infants, an unhealthy state of the 
mother's or wet-nurse's milk, the use of too rich a preparation of cow's 
milk, milk obtained from an unhealthy cow, or a food composed of too 
large a proportion of farinaceous material, are the most common causes. 
In older children, an unwholesome meal, as a surfeit of cakes and candies, 
tough meats, unripe, or an excess of ripe fruits, the swallowing of a quan- 
tity of skins of grapes, of orange-peel, of the seeds of oranges, or such 
like imprudences or accidents, of all which we have seen examples, will 
sometimes occasion symptoms which we can refer only to acute catarrh of 
the stomach. In such cases the child may escape any serious conse- 
quences if it rejects, by vomiting, the improper food, soon after it has been 
taken. Or it may have an attack of cholera infantum or cholera morbus, 
and either recover its usual health -in a short time, or pass through a longer 
or shorter illness, as the result of these disorders ; or, lastly, the unhealthy 
food* may be retained for a longer time than usual in the stomach, and act- 
ing as a local irritant on the gastric mucous membrane, may set up a true 
and more or less severe form of the disease we are considering. 

Anatomical Appearances. — Death is so rare a consequence of gas- 
tritis alone, except in the form produced by the direct application of irri- 
tants to the organ (and even in such, recovery appears to be the rule, since 
all the eight cases referred to as reported by Dr. Luzsinsky, recovered), 
that it is difficult to present a description of the lesions characteristic of 
this variety of the disease. M. Billard, however {Mai des Enjnnh, p. 353), 
gives a ca*e from M. Deni.s, and one observed by himself. M. Denis found 
the raucous membrane of a deep brown color, of a fetid odor, reduced here 
and there to a state of putrilage, and everywhere easily removed in soft- 
ened strips. A fluid of the color of lees of wine, wiis found macerating the 
chaoged mucous membrane, and this he could ascribe only to gangrene 
from excegflive inflammatory action. The case ob.served by Billard oc- 
curred in a girl three days old, who was brought to the infirmary with a 
quantity of V>lacki.«h bloofl pasjjcd into the napkins, and also vomited. 
The child died on the following day. The mouth and resophagus were 
healthy, but the mucous membrane of the stomach was completely de- 
8troye<l, not far from the cardiac orifice, over a space as large Jis a thirty 
80U8 piece. The centre of this space was stained with blackish blood, and 
its edges, irregularly fringed, were blackened and looked as though they 
had been burned. Outside of this dark circle, the mucous membrane was 
thickened, of a violet-red color, and easily reduced to a pulp. The whole 
surface of the organ was lined with semifluid matters, of a bistre color, 



376 GASTRITIS. 

mixed with saDguinolent strise and the mucous membrane beneath these 
matters was very thin and discolored, especially near the pylorus. The 
small intestine was stained yellow with bile, and contained fragments of 
coagulated blood. The large intestine was healthy. The liver was blood- 
less and pale; the spleen small and but slightly injected. No clue is given 
as to the cause of this grave lesion. 

The gastric lesions belonging to catarrh of that organ are very often met 
with, as we have already stated, but are almost always associated with 
changes in the intestinal mucous membrane. They are observed in severe 
indigestion, in simple and inflammatory diarrhoea, and in cholera infan- 
tum. For a full account of the histology of this lesion, we must refer the 
reader to the essay on Gastritis and Acute Gastric Catarrh, by Dr. Wilson 
Fox, in the System of Medicine, edited by Dr. J. Russell Reynolds. We 
shall, however, quote the shorter description given by Dr. Niemeyer {op. 
cit, vol. i, p. 476), of acute gastric catarrh. He says: " We seldom have 
the opportunity of seeing the remains of acute gastric catarrh in post-mor- 
tem examinations ; when we do, the gastric mucous membrane is found 
reddened in spots by a fine injection ; its tissue is relaxed, and its surface 
covered with a layer of tough mucus. But more frequently, especially 
among children who die with the symptoms of cholera infantum, the au- 
topsy gives negative results, except as to appearances which will be de- 
scribed hereafter. This does not appear strange when we remember that 
the capillary hypersemias of other mucous membranes, which we have been 
able to observe directly daring life, leave no trace after death, and that a 
relaxation and partial loss of epithelium, which we have regarded as the 
most probable cause of the extensive transudation in cholera infantum,. may 
be very readily overlooked in the dead body, and can very rarely be ob- 
served with certainty." 

The description of the anatomical appearances in gastritis will not be 
complete without some reference to a lesion which, some ten or twenty 
years since, was thought to be one of great importance in children. This 
lesion, known by the names of softening or gastro-malacia, was supposed 
by some to constitute a distinct pathological entity, and to be the result in 
most cases of inflammatory tissue-changes determined by many different 
causes. Even then, however, not a few observers believed that the lesion 
was a post-mortem change, and not the consequence of changes caused by 
disease during life. This latter opinion has continually gained ground, 
until now it is generally believed that, when present in a marked degree, 
it is in fact a cadaveric change. Niemeyer (op. cit., vol. i, p. 476) says 
that the gastro-malacia or softening of the walls of the stomach, found on 
autopsy in children, is always a post-mortem appearance, and that " if a 
child dies who has had vomiting and purging from abnormal fermentation 
in the stomach, and if there are still fermenting substances left there, the 
fermentation will not be arrested by the gradual cooling of the body. 
When the circulation ceases, the stomach can no longer resist the decom- 
position, which then extends to it also, just as the stomach that has been 
cut out of an animal and filled with milk, softens if left only for a short 
time in a warm place. Hence physicians who consider softening of the 



SYMPTOMS. 377 

Stomach as a post-mortem appearance, may also predict it with certainty 
when a child that has died of cholera infantum had eaten milk, or any 
other easily decomposed substance, shortly before death." 

That a certain degree and kind of softening does, however, attend upon 
catarrhal inflammation of the gastric mucous membrane, as a result of 
faulty nutrition of the tissues during life, is probably quite as true as that 
the extensive white softening of one or more of the coats of the organ, not 
unfrequently met with, is the consequence of a post-mortem change. Thus 
Dr. Wilson Fox {loc. cit.j p. 858) asserts, that the softening of the mucous 
membrane which accompanies acute catarrh is totally distinct from the 
post-mortem softenings which are distinguished by the transparency of the 
tissues. *' It rarely exists," be says, " to any marked degree, except in ex- 
treme cases, but there is always a certain diminution of resistance to the 
finger-nail or to the scalpel, which materially assists, when conjoined with 
opacity and thickening, in distinguishing this condition. Louis's test of 
the extent to which it can be torn from the submucous tissue is a less 
available one, and applies rather to the states of post-mortem solution than 
to this condition." 

Symitoms. — It is very difficult to give an accurate account of the 
symptoms of inflammation of the stomach, for the following reasons : they 
have not as yet been studied with a sufficient degree of care ; gastritis is, 
as was stated in the early portion of this article, rarely idiopathic, but 
almost always a secondary affi?ction in the course of other maladies; the 
symptoms which betray it resemble so closely those of intestinal diseases, 
as to make it very difficult, if not impossible, to draw a distinction between 
the two; and lastly, in the great majority of cases, gastric complaints 
coexist with intestinal. 

The most important symptoms are vomiting, diarrhoea, loss of appetite, 
thirst, epigastric tenderness, sometimes tension of the abdomen, and slight 
febrile reaction. 

Vomitiuf; is the most important of the diflferent symptoms of gastritis. 
It is not, however, according to MM. Killiet and Barthez, invariably pres- 
ent. It was observed by them particularly in cases following the admin- 
istration of active remedies, while in those which occurred spontaneously, 
it was much less common. It shows itself especially after the taking of 
food or drink. Sometimes when the stomach is empty, there is simply 
nausea and retching. In severe cases the vomiting is frequent, and accom- 
panied by violent straining and pain. Dlarrhrxi exists in most cases, 
whether the attack be one of simple gastritis, or accompanied with ent(!ritis. 
The appetite is generally lost or greatly diminished. Thirst is commonly 
acute, and often intense. The tongue is described by some writers as being 
generally red, and srjmetimes smooth and glazed. The authors above 
quoteil, state, on the contrary, that it presents nothing p<;culiar in most 
cases. It was generally moist, only slightly colored, covered with a white 
or yellow coat of variable thickness, and in some rare instances, red on 
the edges and tip, or gluey, or even dry and harsh. As a general rule, the 
abdomen is normal, according to the same authors, though in some cases 
there is more or less swelling and tension. According to most writers there 



378 GASTRITIS. 

is generally tenderness on pressure in the epigastrium. Infants and young 
children are commonly restless and uneasy, as though in more or less pain, 
while those who are older complain of burning in the region of the 
stomach. It is well to remark that MM. Rilliet and Barthez state that 
tenderness on pressure often exists, not at the epigastrium, but in one of the 
iliac fossie, or at the umbilicus, even when the stomach alone is inflamed. 
The condition of the circulation, and indeed all the symptoms, depend so 
much upon the nature of the concomitant malady, that it is difficult to 
ascertain what are their real characters in simple gastritis. Most writers 
agree thai fever usually accompanies the disease, and that it is commonly 
of the remittent type. It is certain, however, from other observations, 
that it is not always present. 

In very violent cases there are added to the symptoms just described, 
those indicative of an adynamic state of the nervous system: prostration, 
cool or cold skin, with perspiration ; weak, rapid pulse ; singultus ; some- 
times convulsions, and death. The symptoms which have just been de- 
tailed as indicating the presence of gastritis, do not generally exist alone. 
They are much more frequently than not associated with other symptoms, 
which show the presence of intestinal disease in the form either of simple 
or inflammatory diarrhoea. That they do sometimes, however, exist alone, 
and that, too, independently of the action of irritating drugs, or of corro- 
sive poisons, we cannot ourselves doubt, since we have several times seen 
them follow attacks of simple indigestion. In such cases, we have met 
with all the symptoms usually supposed to indicate an inflamed state of the 
gastric mucous membrane, — repeated and obstinate vomiting, epigastric 
tenderness, entire loss of appetite, and more or less acute fever. We have, 
to be sure, never seen a post-mortem examination of such a case, for we 
have never yet known one to prove fatal. Whether we call such an attack 
gastritis, acute catarrh of the stomach, or embarras gastrique, matters not 
much. It is the condition which has long been looked upon as indicating 
an inflammatory state of the gastric mucous membrane, and until we have 
more positive evidence than has yet been adduced, that inflammation has 
nothing to do with it, we shall deem it best to retain the old title. 

Diagnosis and Prognosis. — The diagnosis must rest chiefly on the 
existence and frequency of vomiting, on the presence of epigastric pain or 
tenderness, of swelling and tension of the abdomen and excessive thirst, 
and on the absence of other disease which might account for the illness of 
the child. 

The prognosis will depend on the severity of the gastric and constitu- 
tional symptoms, and on that of the concomitant disease, when the attack 
is secondary. When there is incessant and obstinate vomiting, so that not 
even water in small quantities can be retained after several hours of sick- 
ness, when the tongue is red and glazed, or dry and brown, and when 
adynamic symptoms make their appearance, and emaciation makes rapid 
progress, it is much to be feared that extensive organic change has taken 
place, and that the case will prove fatal. 

Treatment. — The two most important points in the treatment are the 
withdrawal of the causes that may have produced, or may tend to keep 



TREATMENT. 379 

up the disease, if these cau be detected, and strict attention to diet. When- 
ever, therefore, the symptoms have made their appearance after the ex- 
hibition of |K)\Yertul drugs, as tartar emetic, kermes mineral, or cathartics, 
their use ought to be instantly suspended. The child should be put on the 
strictest diet. If at the breast, it must be allowed to nurse only at rare 
intervals, and to take but little at a time. If fed on artificial diet, it 
should be restricted to barley- or arrowroot-water, to very weak milk and 
water, or to small quantities of milk diluted with lime-water, in the pro- 
portion of a third or a half of the latter. This is one of Dr. Chambers's 
favorite prescriptions, and is an admirable one. Nothing solid and no 
rich liquid nourishment ought to be allowed, unless the child is in a state 
of weakness and debility from previous or concomitant disease, such as to 
make it absolutely necessary to endeavor to maintain its strength. Bil- 
lard even recommends that the child be sustained by means of nutritive 
enemata, while the digestive function is allowed a total rest. 

Antiphhrfistics are useful and proper when the disease occurs in a strong 
and healthy child, when it is associated with fever, and when there is 
nothing in the nature of the accompanying disease, if it be a secondary 
case, to prevent their employment. The most suitable mode of depletion 
is by leeches, which should be applied to the epigastrium. It is best to 
take but a \ery moderate quantity of blood, for fear of exhausting the 
patient. After the use of the antiphlogistic remedy, a warm bath will be 
found of great service in moderating the heat of the skin and rendering 
the child more comfortable. Small pieces of ice ought to be put into the 
mouth occasionally as a refrigerant, or small quantities of iced drinks 
may be allowed from time to time. As soon as the bleeding from the 
leech-bites, if leeches have been employed, has ceased, a warm light mush 
poultice to the epigastrium is a valuable and useful remedy. Some writers 
recommend the use of blisters to the epigastrium. We should much pre- 
fer a warm poultice or the occasional application of a mustard poultice. 
OpinttJ* are iLseful in allaying nausea and vomiting, and appear to exert a 
favorable influence on the progress of the disease. 

When vomiting is frequent an(f troublesome, it may generally be al- 
layed by the administration of lime-water and milk, given in teaspoonful 
quantities every fifteen minutes or half hour; by observing the precau- 
tion of allowing the fcx»d and drink to be given only in the smallest quan- 
tities (from a tea.'^iKxmful to a tablespoonful) and at considerable inter- 
vals; by the application of warm cataplasms over the abdomen, or a spice- 
pla-ier to the epigastrium ; or, la.*itly, by the exhil)ition of a few drops of 
laudanum or paregoric, to be rcfx-ateci if necessary. If the child becomes 
weak and exhausted, with coolness and abundant moisture upon the limbs, 
we must resort to the ad mini*»t ration of some kind of stimulant. The best 
is veak brandy and water, given in very small quantities; or we may em- 
ploy wine-whey, or milk punch, or the aromatic spirit of hartshorn. 



380 ENTERO-COLITIS. 



ARTICLE II. 

ENTERO-COLITIS OR INFLAMMATORY DIARRHCEA. 

Definition; Frequency. — By entero-colitis or inflammatory diarrhoea, 
we mean that form of diarrhoea which presents, during life, in febrile re- 
action at some period of its course, in marked constitutional disturbances, 
and in the mucous, muco-purulent, or muco-sanguineous stools, the proofs 
of inflammatory changes in the intestinal mucous membrane ; and which 
exhibits, after death, the tissue-changes in the small and large intestines 
which are regarded as the products of inflammation of those organs. 

The disease is one of the most common and one of the most fatal of 
childhood. Few young children die in the foundling hospitals abroad, or 
in the hospitals and almshouses of this country, from insuflicient or im- 
proper food, but die of this affection. Many, a large majority, we think, 
of the deaths accredited to cholera infantum belong to this disorder. The 
true choleraic disease is constantly passed through with safety, but is fol- 
lowed by a long, obstinate, exhausting diarrhoea, which is in truth an in- 
flammatory diarrhoea occurring as a sequel to cholera. 

A large proportion of the cases of summer diarrhoea are, from the be- 
ginning, cases of this kind ; or they commence as merely functional dis- 
turbances of the intestine, and run, sooner or later, into the disorder we 
are now considering. It is one of the most important diseases of young 
children, especially in this country, where our long summer heats, and the 
filthy condition of many parts of some of our most famous cities, give it 
a degree of prevalence and fatality which raise it to the rank almost of a 
pestilence. 

We believe that most of the cases of diarrhoea in children, no. matter 
what may have been the exciting cause* at the start; whether a constantly 
improper diet, as in hand-fed children ; whether ill-judged experiments in 
new foods by the mother or nurse; whether the accidental use of unwhole- 
some food ; whether summer heats, exposure to unhealthy and foul ex- 
halations, crowding, malarial or epidemic causes, dentition, residence in 
cities, or what not, are prone to end, and nearly certain to end, if they 
become chronic, in this disease. This opinion is the result of our experi- 
ence in private practice, in this city, during thirty years. It is curious, 
too, and it is confirmatory of the correctness of this opinion, that in our 
armies during the late war, diarrhoea, whenever it became chronic, exhib- 
ited lesions which are best indicated by the term entero-colitis, if we are 
to use a name based upon the anatomical lesions of the disorder. 

Entero-colitis, then, is undoubtedly one of the most frequent of chil- 
dren's diseases, though it is impossible to determine accurately the mor- 
tality it occasions in this city, from the returns as at present made by our 
physicians. 



FREQUENCY — CAUSES. 381 

Thus duriiiir the seven years, 1862-1868 inclusive, there were 7273 
deaths under five years of age in this city, from the three diseases, cholei*a 
infantum, diarrha\\, and dysentery ^^not to include a compamtively email 
number returned as due to colic, marasmus, inflammation of the stomach 
and bowels, aphtha?, etc.). Of these, as will be seen by inspection of the 
accompanying table* (see p. 382), by far the greater proportion, namely, 
5963, are recorded as due to cholera infantum. Our extended opportuni- 
ties of observing the diseases of children in this city have, however, led 
us to the conviction already expressed in the remarks which preface this 
article, that the great niaj«irity of these cases should in reality be en- 
titled entero-colitis, while the true choleraic disease, to which alone the 
term cholera infantum should be restricted, is a comparatively infrequent 
aflTection. 

We may appreciate yet more accurately the importance and frequency 
of the disease, by reference to the statements of M^f. Rilliet and Barthez, 
who say (lere edit., t. i, p. 483), that, taking into consideration all the cases 
they observed, including tubercular cases, they find that of every two 
children that die, one presents a more or less serious lesion of the large 
intestine. They add: "If it be recollected that this holds true particu- 
larly in regard to younger children, it will be seen that it is rare for a 
child to die between two and five years of age, without having either colitis 
or softening of the large intestine." Bouchut states that entero-colitis is 
one of the most dangerous afl[*ections of children at the breast : '* It is the 
most common of all those incident to that age" (p. 210). 

We shall describe two forms of the disease, the acute and chronic. The 
acute form is accompanied by active and inflammatory symptoms from 
the first, and runs its course in a few days or weeks; the chronic form is 
UDaccom{)anied by acute symptoms, and lasts several weeks or months. 

Causes. — The two most important causes of this disease amongst us, 
are improper alimentation and the heats of summer. The improper ali- 
mentation consists in an unhealthy state of the nurse's milk, or, what is 
much more common, of some improper kind of artificial nutriment; of the 
latter, the kind of food most apt to produce the effect, is one composed 
exclusively or in considerable proportion of some of the feculent sub- 
stances, which constitute so large a portion of the diet of children through- 
out the civilized world. To prove the truth of this assertion, it is only 
Decessary to quote the opinions of those who have most c-arefully studied 
the subject. M. Valleix ( Guide du Med. Prat., t. iv, p. 60, 61 , and Bulletin 
Ghi, de Therap., article Acute Enteritis of Adults and New-born Children, 
March, 184o), clearly assert*, that the most frequent cause of muguet, 
which he believes to be essentially connected with enteritis, is a too exclu- 
sively feculent alimentation. In the article last cited, while speaking of 
the great importance of thU t^ause, he says : " What proves that my asser- 
tion is not hypothetical is, first, that all the deaths from enteritis in chil- 

> We are indebted to the courtety of Mr. Chambem, the clerk of the Board of 
Health in thi» city, for the opportunity «'f collating portions uf this table from the 
m<»niblj rvUim» of mortality calculated by him. 



382 ENTERO-COLITIS. 

Tahle showing the Monthly Mortality for the last Seven Years from 
Years of Life ; compared with the Total Monthly Mortality 



Month. 


1862. 


1863. 


1864. 


1865. 


Mortality. 




Mortality. 


t 

It 

a 


Mortality. 


n 

1 


Mortality. 


t 

a 

1 


— a 

In 

^-2 2 
111 


Total 


5"^ 

^ a 
s « 

III 

IP 

g«5 


Total 


h 


Total 


ci ~ 

ill 

m 


Total 


Jan., 


1 
2 
4 


1314 


32.46° 



3 
3 


1061 


38.25° 


1 


5 


1302 


33.28° 


1 

6 
3 


1373 


26.78° 


Feb., 


1 
3 

1 


1080 


32.70° 


5 
3 
2 


1122 


35° 



3 



1434 


35.97° 


2 
2 
1 


1550 


32.59° 


March 


2 
2 
3 


1204 


40.25° 



2 

7 


1172 


37 26° 


4 

1 
5 


1894 


40.5° 


3 
1 

2 


1868 


47.94° 


April, 


3 
1 
4 


1213 


£0.61° 


2 
5 
6 


1488 


49.80° 


2 

2 
6 


1377 


50.58° 


5 
3 
4 


1411 


56.46° 


May, 


9 
4 
5 


1343 


63.70° 


5 

1 
6 


1060 


64.63° 


10 
5 
8 


1529 


67.20° 


10 

6 

7 


1227 


63.39° 


June, 


20 
3 
8 


1002 


69.14° 


14 
2 
5 


961 


68.76° 


74 
11 
14 


1245 


72° 


184 

. 10 

20 


1690 


76.73° 


July, 


300 
21 
31 


1767 


7523° 


313 
17 

38 


1859 


77.07° 


259 
24 
32 


1643 


76.08° 


364 
52 
41 


1838 


77.82° 


Aug., 


217 
19 
22 


1755 


76.70° 


464 
25 

'28 


2044 


79.46° 


250 
27 
31 


1956 


79 40° 


245 
42 
23 


1759 


74.74° 


Sept. , 


60 
4 
9 


1037 


69.36° 


105 
15 

9 


1453 


64.73° 


28 
16 
10 


1251 


65° 


44 

14 

7 


1040 


72.68° 


Oct., 


15 
5 
4 


1235 


58.32° 


14 
4 
5 


1104 


56.08° 


9 
8 
4 


1144 


54 75° 


15 

12 

5 


1C84 


54.88° 


Nov., 



2 
5 


1021 


45.20° 


5 

1 


1061 


47.72° 


2 
2 

1 


1212 


45.80° 


9 
8 
3 


1285 


45.35° 


Dec, 




1 
2 


1124 


36.06° 


3 
2 

1 


1404 


35.41° 


2 
2 
4 


1595 


36.77° 



2 
3 


1044 


37.39° 


Total, 


808 






1120 






862 






1139 

1 







FREQUENCY — INFLUENCE OF SEASON AND TEMPERATURE. 3S3 



Cholera Infantum, Dysentery, and Diarrhcea, during the First Five 
FROM ALL Causes, and thk Mean Monthly Temperature. 



1860. ; 

1 


1867. 




1868. 


1^. 


»; 


a 
> 


1 








] 


Mortality. 




Moktalttt. 




Mortality. 




s:2S 


«2 


















.i< = - 


>, 






2 

il 

Si 

= 




2 
il 






2 

3 


•2 = rt 

Is? 

S £c 


11 

is 

c 


u 

It • 
I'- 

r 

s 

« 




ToUl 


h 

III 

rr — "^ 


ToUl 


h 


Total 





i 


1 


3i 




2 






^ 






1 


1402' 29.31°i 


11376 25.89° 


2 


1249 


30.12° 


2 


12964 


30 87° 


4 


1 i 


^1 


1 






n 






1 




3 







1 


u 




o 


11 5»; 34.14= 


2 


1042 40.21° 





1063 26.65° 


2| 


1206f 


33.89° 


(» 




3 









1 






3 i 


1 


3 




1 


1 


21 






' 


1082 40.85° 


1 


1094 38° 


1 


1096 41.12° 


n 


1344f 


40.85° 


3 




2 




1 




H 






6 




1 




9 


1 


4 






3 


1034; 66 06°' 


2 


1088 54.13°; 


5 


1357 48.24° 


3 


1281 1 


52.27° 


4 









2 


1 


35 






8 




7 




4 




^ 






1 


1304 61.37° 


2 


1260 


59.44° 


1 


917 59.66° 


2« 


12342 


62.77° 


4 


1 1 


3 






6 




U 






r>S 




38 , 




71 




67 






2 


1168 73.04° 


6 


980 


72.19° 


8 


1201 71.99° 


6 


1178} 


71.97° 


10 j 1 


5 






7 






9f 






427 ' ' 


423 i 




423 






358a 






21 -2047 80.87° 


23 


1795 


76.48° 


14 


1900 


80 94° 


24i 


1837 


77.71° 


34 






81 






32 






34j 






.'■;•'»■. 






265 






327 






3046 






;•) 2401 


72.6** 


26 11294 


75.10° 


19 


1570 


78.42° 


27^ 


18254 


76.62° 


41 






25 






34 






291 






89 






88 






128 






77^ 






16 


1862 


69.42*» 


18 


1012 


6821° 


14 


1858 


68.80° 


13 


1215^ 


68.31° 


13 






»! 




24 






^^ 






55 






24 




20 






152 






8 


182^ 68.86» 


1177 


67.66° 


2 


955 


54.08° 


4^^ 


1218f 


56.3° 


15 






10 




3 






^ 






r, 






6 




8 






81 









1087 


48» 


2 871 


47.79° 


2 


878 


46.91° 


24 


1052} 


46.68° 


4 






6 











n 






2 






1 




1 






9 


2 


W2 88.630 


2 974 


81.78° 





1154 


32.16° 


M 


1191 


34.7° 


3 




2 






8 






2? 






1252 






1040 






1057 













384 ENTERO-COLITIS. 

dren that I have seen, occurred in those who had been placed upon this 
kind of regimen, and, second, that the disease did not occur in any of 
those observed by me in private practice, for whom I had directed an 
exclusively milk diet up to four, five, or six months of age." He adds 
that M. Trousseau had arrived at similar opinions, after studying the same 
diseases at the Necker Hospital ; and that he, on account of the danger 
of a system of diet disproportioned to the digestive powers, recommended 
that children be confined almost exclusively to the breast until after the 
first dentition is completed. Barrier, speaking of the follicular diacrisis 
(op. ciL, t. ii, p. 40), states that the artificial food given to children at the 
period of weaning is a frequent cause of the affection, and that of all the 
different kinds of food habitually employed at that period, feculent sub- 
stances are the most injurious. We have frequently known entero-colitis 
to follow the employment of artificial diet, either alone, at the period of 
weaning, or in children who were partly nursed. Children fed wholly on 
artificial diet from birth rarely escape, according to our experience, attacks 
of the disease, which in many prove fatal. We have, on several occa- 
sions, seen children recover rapidly from such attacks, after suffering more 
or less for weeks, by the suspension of a diet consisting wholly or in too 
large proportion of farinaceous materials, and the substitution of one com- 
posed of milk and cream, prepared with gelatin, and containing a very 
small quantity of arrowroot, rice, or wheat flour (see article on thrush, 
page 332). It is not merely the quality, but the quantity also of artificial 
food that proves injurious to infants. Overfeeding has always been recog- 
nized as a fruitful source of bowel complaints in early life. Another cause 
is the preparation of the food in too thick and rich a manner, thereby 
overtasking the stomach, intended during the early months to receive only 
the thin milk supplied by nature. The custom, therefore, of feeding in- 
fants on thick oatmeal gruel, with but little or no milk, on what is called 
cracker victuals (pounded crackers with water and sugar, or milk), on 
thick bread and milk, on preparations of rice of too solid a nature, or, 
indeed, on any kind of diet not consisting chiefly of milk, and in which 
feculent substances enter merely as secondary constituents, may safely be 
asserted to be the most frequent cause of the disease under consideration. 

An unhealthy character of the milk of the nurse is also known to be a 
cause both of simple diarrhoea and entero-colitis. When the granule-cells 
which exist as a physiological element in the colostrum secreted during 
the first few days after childbirth, continue to be present after that period, 
the infant is almost certain to suffer from entero-colitis, and not unfre- 
quently to die, unless weaned or transferred to another nurse. So, also, 
when the milk departs widely from the normal characters which it should 
possess, as described at page 338, when the nurse is liable to vivid moral 
emotions of any kind, or when addicted to intemperance, the child is very 
apt to suffer either from the disease under consideration, or from simple 
diarrhoea. 

That the heats of summer are a most fruitful cause of this disease, no 
one can doubt who will glance at the table given at pages 382 and 383, 
where the mortality from cholera infantum, dysentery, and diarrhoea. 



CAUSES. 385 

under five yeai-s of age, in this city, during the seven years from 1862 to 
18G8 inclusive, is given. 

The table shows at a glance, the number of deaths from these diseases 
enumerated, during the period of life specified, in each month of every 
year, with the mean temperature of each month, and also the total mor- 
tality at all ages and from all causes in each year. The reader must not 
forget what we have already stated, that there is every reason to suppose 
that a large majority of the cases reported under the head of cholera in- 
fantum are, in fact, cases of entero-colitis, — at least what we have proposed 
to call entero-colitis, as opposed to the less frequent choleraic disease to 
which we restrict the term cholera infantum. It will be seen, in this table, 
that the two months of July and August furnish by far the largest propor- 
tion of deaths. In these two months, when the mean temperature is noted 
between 70^ and 80° Fahr., the deaths from this disease ran up to three 
and four hundred and upwards; whilst in June and September, when the 
temperature ranges between 60° and 70°, the deaths average between 60 
and 80, and rarely rise over 100; and in January and December, with a 
temj>erature of from 30° to 40°, they number from between 3 and 5 to 10 
and 15. The efl^ect of season is here so striking that it nuist interest all, 
and can leave no doubt, we think, in the mind of the reader, but that the 
elevated temperature of summer is the main cause, in this city, of the 
fatal intestinal disease we are considering. Whether heat alone may act 
upon the system of the child to produce this result, or whether it acts al- 
ways by determining noxious gaseous products from the decomposition of 
animal and vegetable substances thrown into our streets, has not yet been 
demonstrated. From the well-known fact, however, that those children 
suffer most who reside in the more filthy and crowded part of the city, 
whilst the disease is very much less common in the open country, and in 
the cleaner and better ventilated parts of the city, we may safely conclude 
that it is not heat alone that usually causes the disease, but that the 
emanations arising from garbage of various kinds, and the imperfect 
ventilation of houses built in narrow and crowded streets, have much to 
do in its causation. 

We referred, in the general remarks at the beginning of this chapter, to 
the resemblance of the chronic diarrho'a of our armies during the late great 
war, in its mode of causation, symptoms, anatomical lesions, and the eflTects 
of treatment, to the chronic form of entero-colitis in childhood. 

Any one who will refer to the work of Dr. Woodward, already fpioted, 
or to the essay on Oimp Dinrrhra and IhjMeufpnj, by Dr. S. B. Hunt, in 
the United StateJ! &ijutary Commimion Contributions relatinrj to the Causa- 
tion and Prevention of Disease, and to Camp Diseases, etc. (New York, 1867) ; 
or to the InreMifjations upon the Diseases of the Federal Prisoners ran fined 
in Camp Sumter, Anderfonville, etc., by Joseph Jones, M.D., published in 
the volume just alluded to; will find ample proof that improper diet, with 
heat, overcrowding, and want of cleanliness, will give rise to chronic diar- 
rhrea, the essential lesions of which are to be found in radical blood-changes, 
pers'erted nutrition, and a localization on the alimentary canal in tho form 
of entero-c(jliti.-, vf*ry niuf}; like the disorder we are describing. Dr. Wood- 



386 ENTERO-COLITIS. 

ward says, in fact, in speaking of the nature of this affection (chronic diar- 
rhoea), at page 251 : " From the account given above of the pathological 
anatomy of the disease, there can be little doubt that this affection is to be 
regarded as consisting essentially of a chronic inflammatory process, in- 
volving primarily the mucous membrane of the ileum and colon. It may, 
in fact, be described simply as a chronic ileo-colitis, with a tendency to 
ulceration." Dr. Hunt {loc. cit., p. 294) says : " The essential fact in the 
pathology of all these various forms of flux is the same, and autopsies re- 
veal no distinction between cases of diarrhoea and dysentery. They are 
alike an inflammation of the colon or of the small intestine, or of both, 
attended by ulceration of the mucous membrane. The solitary follicles of 
the colon are seen to be enlarged simply, or ruptured, with punched-out 
ulcerations following. The intestinal wall is thickened and changed in 
color to a red, browu, black, or greenish hue." 

It may seem, at first view, visionary and wild to compare the chronic 
entero-colitis or inflammatory diarrhoea of childhood to the same disorder 
in armies and camps ; and yet we think there is a most striking analogy 
between the two as to causation, symptoms, anatomical lesions, pathology, 
and the results of treatment. The main causes are the same: improper 
diet ; elevated temperatures, the high temperature of the summer season 
in children, and of the Southern States in the armies; overcrowding, 
with foul air in camps and cities : the symptoms are very much alike, a 
most obstinate diarrhoea, with great constitutional sufi^ering and emacia- 
tion; the same lesions are present, only less advanced and extensive in 
most cases of children ; and very much the same results follow treatment : 
as in both diet is found to be more important than drugs, and removal 
North in the armies, and in children removal from crowded cities or low 
hot regions of the country to more elevated and cooler tracts, are found 
necessary. In children, as in armies, if, at the beginning of the attack, 
the patient is removed from the causes which have produced a simple 
diarrhoea or a cholera infantum, the case is likely to go no further ; but, if 
the same causes are continued in operation, the simple diarrhoea passes 
gradually into the chronic inflammatory form of entero-colitis, and at last 
the patient recovers only when he is removed to a more favorable locality, 
when the diet is changed to a more healthy one, or, in the child, when he 
■drags through a long hot summer, and the cooler weather of October or 
November, and a diminution of the exhalations caused by the summer 
heats in cities, bring at last, in the course of nature, the change which 
was essential to his recovery. 

After the causes just enumerated, the one which appears to exert the 
strongest influence is dentition. That the evolution of the teeth, though a 
physiological process, is a powerful predisposing cause of diarrhoea and 
enteritis, cannot be doubted at the present time. It is one recognized by 
many of the most able writers and observers of the day, and by most 
practitioners. MM. Killiet and Barthez agree with Trousseau in the 
opinion that the simple diarrhoea so apt to occur in children at the epoch 
of the first dentition, is often the origin of chronic intestinal lesions which 
finally reduce them to extreme debility and emaciation. They say that 



I 



CAUSES — MORBID ANATOMY. 387 

c:irefiil investigation will generally show that nearly all the eases of in- 
flammation and softening date either from the epoeh of dentition, from the 
period of weaning, or from the time at which some considerable change in 
the character of the regimen was made. M. Bouchut states that of 110 
children in whom the first dentition was going on, 26 escaped any indis- 
position, 38 suffered from restlessness, colics, and occasional diarrhani, so 
mild as to excite no alarm in the parents, whilst 46 had abundant diar- 
rhcea. In 19 of the last series it appeared coincidently with the fluxion of 
the gums, occurring at the time of emergence of each tooth, and disap- 
pearing eniirely in the intervals ; in the remaining 27, in all of which the 
process of dentition was diflicult, the diarrluva persisted and gradually as- 
sumed the characters of entero-colitis. M. Legendre and M. Barrier i^Ioc. 
cit.) both agree in ascribing very great eftect to the influence of dentition 
in the production of diarrhea and entero-colitis. The former asserts the 
diseases referred to to be much the most frequent between the ages of six 
or seven months and two or two and a half years, which includes exactly 
the period occupied in the first dentition, while they are only met with ex- 
ceptionally after three years of age. 

The act of weaning is very apt to result in the production either of sim- 
ple diarrhoea or entero-colitis, in consequence, no doubt, of the irritation 
set up in the gastro-intestinal surface, by the change of food made at the 
time. The diarrhQ?a which occurs at this period was formerly, and is still, 
not unfrequently, called weaning-brash. Dr. Stokes {Cyclop, of Med., Art. 
Enteritis ) says of this disease that it " is manifestly an acute enteritis, pro- 
duced by the change of food, and in which nature seeks to relieve the in- 
flammation by a supersecretion." 

Entero-colitis is prone to occur as a secondary affection in many of the 
acute diseases of children. It is by far the most common in the course of 
the eruptive fevers, particularly measles, and in that of typhoid fever. It 
is also a frequent complication of the latter stages of pneumonia. 

That children of feeble constitution and lymphatic temperament are 
more disposed to the disease than others, is sutflciently proved by the evi- 
dence of various observers. Lastly, that the incautious and excessive use 
of perturbing systems of medication, addressed to the digestive tube, often 
occasions diarrhoea and entero-colitis, is fully proved by the researches of 
MM. Rilliet and Barthez, and by our own experience. 

MoHBiD AxATO-MY. — Seat OF DisEASE. — It has bccn already stated, 
that the alterations of the large intestine are, as a rule, much more frecpient 
and serious than those of the small intestine. It appears from the re- 
searches of MM. Killiet and Barthez, and Legendre, that enteritis rarely 
exists alone ; whilst colitis by itself, or combined with enteritis, is quite 
frequent. M. Legendre states that inflammation of the small intestines 
never occurs without corroponding lesions of the large bowel, while in 28 
cases of diarrha^a, he found the large intestine alone diseased in 9. From 
a table of different intestinal lesions, given by Killiet and Barthez (op. ci7., 
t, i, p. 692), it appears that they have met with 45 cases of erythematous, 
pseudo-membranous, ulcerative or pustular enteritis ; with 113 of the same 
forms of coliti- : with 00 of follicular enteritis; 64 of follicular colitis; 



388 ENTERO-COLITIS. 

and with 28 of softening of the small, and 35 of softening of the large 
intestine. Dr. J. Lewis Smith (op. cit., p. 367), offers an analysis of the 
post-mortem appearances in 82 cases of intestinal inflammation in children. 
The upper part of the small intestine, embracing the duodenum and jeju- 
num, was found inflamed in 12 cases, while in 51 cases it was free from 
inflammation and of a pale color. The ileum was inflamed in 49 cases, 
and the cjBcal portion, including the ileo-csecal valve, was the part in which 
the inflammation was uniformly most intense, and to which it was often 
confined ; in 13 cases there was no enteritis whatever, and in 16 there was 
no inflammation of the ileum, so that the ileum was inflamed in all but 3 
cases where enteritis was present. On the other hand, in all the cases ex- 
cepting one, namely, in 81 out of 82 cases, there were lesions indicating 
inflammation of the mucous membrane of the colon. In 39 the inflam- 
mation had affected nearly or quite the entire extent of this portion of the 
intestine ; in 14 it was confined to the descending portion entirely, or almost 
entirely; in 28 cases, the records state that colitis was present, but its exact 
location is not mentioned. 

We may add, that, in the quite numerous autopsies we have made after 
death from this disease, we have invariably found the large intestine in- 
volved, the inflammatory lesions being in some cases limited to it, while 
in others they also extended into the small intestine. 

It is, therefore, clearly established, that in the inflammatory diarrhoea 
of children, inflammation of the large is considerably more frequent than 
that of the small intestine, and much more apt to exist alone. The lower 
end of the ileum is the portion of the small intestine which presents the 
most advanced and severe lesions; while in the large intestine the lesions 
are most marked in the caput coli, sigmoid flexure, and descending colon. 

In our description of the lesions of entero-colitis, we shall divide them 
into those found in the acute and chronic forms of the disease respectively; 
a division made for the sake of correspondence with the description of the 
symptoms, although the lesions found in the two stages differ from each 
other only in extent and degree. 

Thus, in the acute stage, the lesions consist of increased vascularity, 
thickening and softening of the mucous membrane of the intestine, and 
enlargement of the intestinal follicles ; while in the chronic form there is 
discoloration, thickening, with infiltration and induration of the walls of 
the intestine, and more or less extensive destruction of the mucous mem- 
brane from follicular ulceration. 

In the acute stage, the increased vascularity (inflammatory hypersemia) 
may present itself as a uniform, more or less intense redness of the mucous 
membrane; an appearance which may sometimes exist in the duodenum, 
but far more frequently is observed in the lower end of the ileum and in 
the colon. More frequently it takes the form of arborescent congestion, 
occurring in patches surrounding the enlarged follicles. The peritoneal 
surface may also be more or less vascular, and quite frequently there are 
little patches of redness and arborescent vascularity, corresponding to the 
bases of the inflamed mucous follicles. 

The thickening of the mucous membrane usually corresppnds to the 



MORBID ANATOMY. 389 

degree of vascularity, and Avheii the latter is but slight, may be scarcely 
appreciable ; while iu other cases, aud especially when associated with much 
enlargement of the mucous follicles and o?{iema of the submucous tissue, 
the thickening is highly marked. The inflamed portions of the mucous 
membrane are also more or less softened, so that they can be detached from 
the subjacent coats more readily than in health. In some instances the 
softening is so extreme that it is impossible to raise up the mucous mem- 
brane in strips at all. These lesions are all mc^t frequent and marked in 
the lower part of the ileum, and in the descending part of the colon. In 
addition to these changes in the color, thickness, and consistence of the 
mucous membrane, the mucous follicles are prominently enlarged. In the 
normal state, the isolated follicles of the mucous membrane of the intes- 
tine, in young children, appear as minute grayish-white bodies, and pre- 
sent a grayish point, the excretory orifice, which is only visible with the 
aid of a lens. In the course of entero-colitis, however, the morbid devel- 
opment which they undergo causes them to present the following charac- 
ters. The isolated glands are enlarged, and seem, therefore, more numer- 
ous than in the healthy condition ; they appear in the form of lenticular 
grains seated in the texture of the mucous membrane, sometimes project- 
ing from its surface, sometimes not, aud in other instances appearing to be 
situated beneath it ; the excretory orifices of the follicles are often enlarged 
and tumid, and easily distinguished under the form of a grayish or blackish 
point in the middle of the gland ; in other cases the orifices cannot be dis- 
tinguished until slight pressure is made upon the crypts, when a drop of 
turbid mucus may be seen exuding through the open point. The color of 
the distended follicles is dull white, rosy, or yellowish ; they are generally 
from one-third to two-thirds of a line in diameter. Dr. Horner (Amer. 
Jour. Med. Sci., Feb. 1829) speaks of them, in this state of development, 
as resembling "small grains of white sand sprinkled over the mucous mem- 
brane, and about the size of a millet-seed." 

The agminated glands or patches of Peyer are found in the same state of 
increaseti development; they are tumefied, and project above the level of 
the surrounding mucous membrane, and the orifices of the follicles are con- 
gested, .«o as to appear as dark points, giving to the patch a dotted, punc- 
tated appearance, which hus been compared to the freshly-shaven chin. 

A little later the enlarged follicles present minute, oval, or round yel- 
lowish spoU< upon their summits, which soften down and allow the contents 
of the follicles to be discharged. The enlarged orifice of the follicle will 
then admit a small probp, an<l may even measure one-half a line in diam- 
eter. It leads into a little cavity, which is the follicular sac. The mucous 
membrane which overhangs this cavity like a friuge, is thus undermined 
and partly cut off* from its vascular supply, so that we may find a process 
of ulceration advancing in it until the base of the distended follicle is ex- 
pose<l, appearing as a small, oval, or round shallow ulcer. 

These various conditions of the follicles may all be seen at the same time 
in a single portion of intestine. The enlarged patches of Peyer often have 
the apf>earance of being ulcerated, but a careful examinatioi] will gener- 
ally show that this is not the case. The appearance depends upon the en- 



390 ENTERO-COLITIS. 

largemeut of the orifices of the glands, upon unequal tumefaction of the 
surrounding mucous membrane, and upon the presence, in the patch, of 
small, irregular grayish points, consisting of pultaceous matter, which 
makes the patch look more uneven and projecting than usual. If, how- 
ever, the pultaceous layer be gently rubbed with a piece of linen, it can 
easily be detached, when the mucous membrane beneath is found red, soft- 
ened, and thickened, but not ulcerated. In comparatively rare cases, how- 
ever, there are superficial erosions of the mucous membrane, covering the 
prominent patch. 

The exact date at which the ulceration of the follicles begins, is as yet 
undetermined, and probably varies greatly in diflferent cases. It fre- 
quently happens, however, that death occurs, especially from the super- 
vention of a choleraic condition, whilst they are still merely in a state of 
enlargement. When, on the other hand, the disease passes into the chronic 
form, the lesions which we have above described become more and more 
extensive. This is especially the case with the lesions of the large intes- 
tine, for it is even more true with regard to chronic than acute entero-co- 
litis, that the chief seat of the disease is in the colon. 

In chronic enterocolitis, the intestine is often contracted, and the peri- 
toneal surface may present patches of discoloration. The thickening and 
infiltration have now affected the submucous and muscular coats, and have 
been followed by induration of the tissues, so that the walls of the intestine 
are often abnormally rigid. This is especially true with regard to the 
lower part of the descending colon and the rectum. The mucous mem- 
brane is seen to be riddled, not with mere superficial erosions, but with 
true ulcers, affecting the whole thickness of the membrane. These ulcers, 
when isolated, are from one to one and a half lines in diameter, oval or 
circular in shape, and either have sharp-cut edges, as though the piece of 
mucous membrane had been cut out with a punch, or the mucous mem- 
brane bounding them is undermined. Frequently, however, these ulcers 
coalesce, and at the same time extend in depth, so that large, sinuous, ir- 
regular ulcers are formed, with thickened, slate-gray, undermined edges, 
and having for their base either the submucous or muscular coats, which 
may be covered with a pultaceous, apparently pseudo-membranous layer, 
of a grayish-white color. These ulcers surround and include irregular 
islets of mucous membrane, which are swollen, infiltrated, vascular, and 
discolored. That the large and deep ulcerations just described, even when 
most extensive, take their start from the mucous follicles, is proved by the 
frequent presence amongst them of other ulcerations of more recent date 
and smaller size, which present all the characters of the follicular ulcer, 
and show clearly the origin of the larger and more advanced ulcerations. 
Occasionally there is a marked deposit of pigment in the bases of the 
ulcers, and in some cases small coagula of blood have been found adherent 
to their bases. 

We have already had occasion to allude to the marked analogy between 
the disease under consideration, and the form of camp diarrhoea described 
by Woodward (op. cit.) ; and one of tjje most powerful arguments in favor 
of the essential identity of the two affections, is the perfect correspondence 



MORBID ANATOMY. 391 

between their anatomical lesions. We present below a snniniary of the 
niierosoopical changes in the intestine during the (levelo])nient of these 
lesions, as determined by the careful investigations of Dr. AVoodward (op. 
cit., p. 246). In the early stage, attended merely with thickening and 
softening of the mucous membrane, microscopic examination shows marked 
multiplication of the connective-tissue cells about the base of tlie follicles, 
and soon the tissue is occupied by great groups of small, rounded, or 
slightly polygonal cells. The delicate layer of muscular tissue imme- 
diately beneath the base of the follicles, presents, at first, enlargement and 
proliferation of its nuclei, whilst later it often ceases to be recognizable, 
being obscured by the luxuriant cell-growth. In the most intense cases, 
the cell-growth here described as attained toward the surface of the mem- 
brane, may take place throughout its whole thickness, and even involve 
the subjacent muscular layer. 

A similar proliferation takes place in the connective tissue, which lies 
between the follicles. The epithelial layer, which invests the mucous 
membrane, and is prolonged into the tubular follicles, ^either is the seat of 
rapid cell multiplication, or is exfoliated and replaced by round granular 
cells from the adjacent connective-tissue cells. The epithelial lining, near 
the orifice of the follicles, appears to undergo these changes most readily 
and with the greatest rapidity. 

The dosed follicles also present rapid cell multiplication, which affects 
the parenchyma of the follicle, as well as the connective tissue of its cap- 
sule and the surrounding cellular tissue. Microscopic examination then 
shows the follicle distended with small, rounded, granular cells, and im- 
bedded in a luxuriant growth of similar cells, which render it almost or 
quite impossible to draw the line where the follicle terminates and the sur- 
rounding connective tissue begins. " Ulceration usually appears to origi- 
nate in the rupture of one of the closed follicles, and the discharge of its 
softened contents into the intestinal cavity. This is followed by the lique- 
faction of the intercellular substance, and the consequent liberation of the 
broods of minute cells, into which the surrounding connective tissue has 
been transformed. Hence results one of the punched-out ulcers described 
above. In the subsequent extension of the ulceration, by which large, 
irregular, sinuous ulcers are produced, the progress seems to take place 
chiefly in the submucous connective tissue, the superficial part of the mu- 
cous membrane resisting the process until undermined, and its nutritive 
supply cut ofT. Hence arises the excavated undermining character of the 
edges of the ulcers. From the anatomical point of view, it will therefore 
be perceived that the morbid prooes.^, in the cases in whi(rh there is no 
ulceration, is es.sentially the same as in those in which ulceration is present. 
The one lesion is only a later stage of the other." 

Not unfrequently there will be found one or more intussusceptions of 
the ileum. Thf#e are usually readily restored, and have cvid(;ntly oc- 
curred during the act of dying. .Smith has, however, " in a few instances, 
found intussusceptions, which sustained the weight of two feet or more of 
intestine, without being reduced, qju\ which, from being in their interior 
more vascular than the contiguous membrane, had probably occurred some 



392 ENTERO-COLITIS. 

hours or days before death, but being sufficiently pervious to allow the 
food to pass, the symptoms of obstruction were lacking." 

The Mesenteric and Mesocolic Glands are nearly always enlarged, the 
most marked enlargement corresponding to the lower end of the ileum and 
the descending colon. The enlarged glands are of a pink color, and rather 
more soft and succulent than normal. 

Stomach. — In the great majority of cases the stomach is quite healthy ; 
in a few instances, however, there may be found congestion of the mucous 
membrane, slight enlargement of the mucous follicles, or softening of the 
mucous membrane, probably cadaveric in most cases. 

Liver. — Many authorities, apparently led by the presence of symptoms 
supposed to indicate disturbance of the function of the liver, have assumed 
that there is in most cases of entero-colitis some morbid condition of this 
organ, but extended observation has disproved this view. 

Thus Hallowell {Amer. Journ. Med. Sci., July, 1847) found, that in 14 
cases, the liver was affected in but 1 case, when it was enlarged ; and 
Smith (op. cit., p. 370) has published the result of 32 post-mortem exami- 
nations in regard to this point, which confirm the same conclusion. Thus, 
he states, " there was no evidence from the post-mortem appearances of 
the liver in these cases of any congestion, or torpidity, or hyperactivity, or 
perverted secretion. The size of the liver was in some cases very different 
in those of about the same age, but probably there was no greater differ- 
ence than usually obtains among glandular organs within the limits of 
health. In most of the cases the liver was examined microscopically, and 
the only fact worthy of note observed was the variable amount of fatty 
matter. Sometimes it was in excess, sometimes in moderate quantity or 
rather deficient, and sometimes in greater amount in one portion of the 
organ than in another." 

The thoracic viscera present no constant or important lesion, though in 
a certain proportion of cases, there may be found more or less hypostatic 
bronchitis with collapse of portions of the lungs. 

When death occurs during the acute stage, the brain presents no lesions 
dependent upon the disease. When the case has been protracted and 
attended with much wasting of the solids and fluids of the body, the 
brain also diminishes in size, and there is frequently found marked excess 
of subarachnoid effusion in cases where the foutanelles have closed; while 
if these spaces still remain unossified they become markedly depressed. 
These appearances are, however, purely passive in their character, and 
depend upon the wasting of the brain. 

Pathology. — The pathology of inflammatory diarrhoea is involved in 
great obscurity. We are now pretty well acquainted with the physical 
conditions under which the disorder is most apt to be developed. Early 
age, the period of dentition, high temperatures, improper food, residence 
in cities, and especially the crowded occupation of small and ill-ventilated 
buildings, in narrow courts and alleys, where unhealthy exhalations arise 
from the decomposition of filth and dirt of all kinds, are the chief condi- 
tions which precede the outbreak of the disease. But how these conditions 
act to produce their effect is still a matter of doubt. To attempt to reason 



% 



SYMPTOMS — DURATION. 393 

upon a matter so full of difficulty seems almost useless, and yet we sliall 
venture to place before the reader some thoughts we have had upon the 
subject. 

There are two broad generalizations which we think may be safely as- 
sumed to be true. 1. An unhealthy food, one incompetent to furnish to 
the body what it needs for the purposes of nutrition, as farinaceous food 
or unhealthy milk, is sure to produce the disorder we are considering, no 
matter how favorable may be the circumstances, in all other respects, in 
which the chiM is placed. 2. The best breast-milk in the world, or the 
most correct artificial diot, will not save a child from this disorder who is 
located in an ill-ventilated house in a dirty and filthy quarter of a large 
city during hot weather. Here the heat to which the child is exposed, the 
heavy air loaded with foul exhalations which it breathes, determines a con- 
dition of the health in which the digestive organs can no longer digest 
properly the food offered them. In both cases the same result is produced. 
In the first, the stomach cannot change the originally improper character 
of the food into healthy material. In the second, the diseased and en- 
feebled organ loses the power to digest even proper food. In both the ali- 
mentary canal is filled with the products of an improperly digested food. 
Whether these unhealthy products in the alimentary canal act chiefly as 
local irritants to the mucous membrane, and thus determine the tissue- 
changes met with ; or whether, as Rilliet and Barthez suppose, some mor- 
bid condition of the blood is brought about, which of itself gives rise to 
the changes in the mucous membrane through a morbid action of the dis- 
eased blood on the nervous system, and particularly on the sympathetic 
nerve:*, we cannot say. Most probably they act in both ways, and the re- 
sultant effects are the consequence of the two trains of diseased action set 
up, the local and the general. 

In either case a constitutional condition is brought about, the essential 
feature of which is a slow innutrition or inanition. It is altogether proba- 
ble, moreover, that a conclition partaking of the scorbutic, must be induced, 
*o that we have, after the disorder ha.s lasted for several days or weeks, the 
general debility of a slow inanition, aud blood-alterations which resemble 
thn-f of scurvy. 

SvMiTfJMs; Duration. — In infants the arufe form of enterocolitis 
generally begins with restles.«ness and fretfulness. The mother observes 
that the child .sleeps less than usual and for shorter periods, and that its 
gleep is uneasy and broken by sighing or moaning, or by occasional expres- 
sion.* of pain flitting acros.s the face. It takes the breast Ic^s frequently, 
and i,« satisfied to nun»e tor a shorter time, showing thereby an evident 
dimiuution of appetite. At the same time it is apt to reject its milk in 
larger quantities than usual, and this is often observed to have a very acid 
smell. After these symptoms have lasted a few days, and sometimes with- 
out them, the |>eculiar symptoms of the disease, the diarrhcea and othfr ab- 
dominal symptoms, make their appearance, and are accompanied by febrile 
reaction in most ca.«»«. 

In older children the acute form may come on suddenly, with diarrlnea, 
\o9e of appetite, thirst, sometimc^s vomiting, abdominal pain and fever from 



394 ENTERO-COLITIS. 

the first; or, as happens very frequently, the case begins with slight diar- 
rhoea, unaccompanied by fever or other signs of sickness, and it is not until 
after several, or eight, ten, or even more days, that signs of inflammation 
make their appearance. 

After the disease is established, the most important symptoms are the 
following. The diarrhoea, w^hich is the most prominent and characteristic, 
presents various characters. In order to appreciate this symptom as its 
importance requires, the practitioner ought always to see the napkins of 
the child at least once, and often more frequently, in the day. It exists 
in almost all cases of entero-colitis, in the erythematous and follicular in- 
flammations, and in the ulcerations and softening which accompany or 
succeed simple inflammation. It is seldom absent, and yet that it is so 
sometimes, is proved by the facts mentioned by MM. Rilliet and Barthez, 
who state that they have calculated, from their cases, that it is wanting in 
about one of every twelve cases of inflammation or softening of the intes- 
tine. They add, however, that it is absent only in slight attacks, and is 
ahvays present when the disease is severe. It varies greatly as to the fre- 
quency, abundance, and character of the stools. It varies also in its mode 
of progress, so that it presents great differences as to all these points from 
day to day, and at diflerent portions of the same day. We may remark, 
in general, however, that in proportion to the severity of the inflammation, 
so is the diarrhoea violent and constant, and that it usually increases as the 
signs of inflammation become more and more marked. It is rare to have 
severe diarrhoea when the anatomical lesion is of slight extent, though this 
does sometimes happen. The number of the stools, as has been stated, is 
exceedingly variable. This depends in great measure upon the violence 
of the case ; for, while in those which present the symptoms of an inflam- 
mation of small extent the stools seldom amount to more than six or eight 
a day, in those in which the evidences of more extensive and severer in- 
flammation are present, there will be fifteen, twenty, twenty-five, or even 
more per diem. The consistence of the stools may vary between that 
which characterizes them in a state of health, and that of the thinnest 
serous fluid. The materials of w^iich they are composed consist chiefly 
of mucus, bile, serum, small portions of feculent matter, portions of un- 
digested casein or other food, and blood. M. Bouchut {loc. cit, p. 219) 
describes those of very young children as presenting the following charac- 
ters : 

1. They are semifluid, homogeneous, greenish, and similar to cooked 
vegetables ; neutral. 

2. Semifluid, homogeneous and green ; often acid. 

3. Semifluid, heterogeneous, greenish, and mixed with yellowish frag- 
ments of ordinary fseces ; neutral. 

4. Semifluid, heterogeneous, greenish, and mixed with fragments of un- 
digested casein ; acid. 

5. Difllueut, greenish, heterogeneous, composed of a large quantity of 
water, in which float yellowish and greenish or whitish particles ; acid. 

6. Diflluent, greenish, like the preceding, and mixed with gas of a 
mawkish and sometimes sourish smell. 



SYMPTOMS — DURATION. 395 

7. Diffluent, completely serous. 

8. Bloody stools are very rare at this age. 

Such are the appearances of the stools in children who have not com- 
pleted the first dentition. After the epoch of the first dentition the disease 
becomes much more mre, and when it occurs, is generally of a milder 
character, so that the discharges ditfer less from their healthy characters. 
Under these circumstances, they are usually less frequent, not often exceed- 
ing six, eight, or ten in the day, and retaining generally their yellow color 
or becoming brownish ; they are commonly of a semifluid consistence, and 
may be called bilious. When, on the contrary, more frequent, they be- 
come fluid, abundant, mixed with mucus, and are either of a light yellow 
or brownish, or more rarely, of a greenish color. In some cases there are, 
in addition to the substances mentioned, pus, which indicates ulceration of 
the lower |X)rtion of the intestine, and fragments of false membrane. 
Moreover, it is very common in older children to observe traces of blood 
in the stools, sometimes in considerable quantities. We may remark that 
we have several times met with stools containing blood in children within 
the year, but much less frequently than after that age. The presence of 
blood generally coincides with small and frequent stools, attended with 
much straining, and often severe pain, and almost always indicates fol- 
licular inflammation and ulceration of the large intestine. 

The serous fluid alluded to sometimes constitutes the whole of the dis- 
charge, so that the napkins are merely wetted through, without any or but 
a very small quantity of solid matter being left upon them. This kind of 
stool is very frequent in the cholera infantum of this country. The odor 
of the stools is important. In the beginning, while the discharges still 
retain some of their natural characters as to color and consistence, it is 
often very offensive, but as the case goes on, and the greenish color pre- 
dominates, it is either sour, or becomes very slight. In some violent cases, 
in which the discharge consists of a watery, dark-brown fluid, the odor is 
fetid. 

After diarrhcea, the most important symptoms arc those which concern 
the form^ sizCf and tewnon of the abdomen^ and the presence or absence of 
pfiin or tenderness on pressure. In infants the abdomen is more distended 
than usual ; but, according to Bouchut, the tension depends on the muscu- 
lar effort made by the child to resist the hand of the physician. He says 
that when it is carefully examined, while the attention of the child is at- 
tracted in some other direction, it is found to be soft and supple, and rarely 
painful to the touch. In older children it is, in many acute cases, but not 
in all, enlarged, s<^»metime8 tense and sonorous, and very generally painiul 
to the touch. The seat of pain is variable, but generally it is one of the 
iliac fossae or at the umbilicus. It is seldom acute, though the child not 
unfrequently shrinks away and cries out, as though it were excessive, from 
fear of the examination. It is easy to distinguish when the pain is real 
and when apparent, by withdrawing the attention of the child, by some 
device, from the examination, in which ca«*e it will cease to notice the pal- 
pation ; or by touching some other part of the brxly, when, if the crying 
and shrinking depend oo fear or nervous excitation, they will be as violent 



396 ENTERO-COLITIS. 

as when the abdomen is touched. Pain to the touch is an important symp- 
tom, as it is very generally indicative of acute enteritis. Gurgling is rare, 
according to MM. Eilliet and Barthez, in ordinary entero-colitis, though 
very generally present in typhoid fever. 

Vomiting is very common in young infants, and is generally repeated 
several times a day. In severe and rapid cases it is a very troublesome 
and alarming symptom. In older children it is much less common, and 
is never really violent, except in some of the most acute cases. In them 
it is confined to the first few days of the attack. 

After the diarrhoea is fairly established, young infants are almost always 
either very irritable, peevish, and restless, or weak, languid, and subdued. 
Their slumber is short, and disturbed, and generally they sleep much less 
in the twenty-four hours than when in health, unlcvSS under the influence 
of anodynes. Older children are generally somewhat restless and irritable, 
but much less so than infants. There is seldom any disorder of the intel- 
ligence, though in acute cases there is sometimes slight delirium, or head- 
ache. Fever exists in all acute cases. It is seldom continuous in infants 
except for the first few days, after which it almost always assumes the 
remittent type. It is marked by increased frequency of the pulse, which 
rises to 120 and 140, or in bad cases much higher ; by heat of skin, often 
intense during the exacerbations ; by thirst and diminished appetite ; and 
by dryness and heat of the mouth. In older children the pulse is not 
generally so high as in infants, and in many of the mild cases the fever is 
very slight or there is none at all. In acute cases, however, it is'sometimes 
continuous, and marked by rapid pulse and great heat of skin. 

The tongue is generally normal, though sometimes red on the edges and 
tip in acute cases. It is seldom dry, except during the fever. The appe- 
tite is almost always lost, and the thirst generally increased, though to a 
less degree than in diseases of the stomach. 

The countenance presents nothing peculiar, except that the features are, 
according to MM. Eilliet and Barthez, drawn down towards the inferior 
portion of the face. Emaciation always takes place as the disease pro- 
gresses, and in very severe cases occurs with the greatest rapidity, so that 
in a very few days the child will be reduced from an appearance of vigor 
and strength, to that of the greatest debility. As this occurs the flesh 
loses its firmness, the skin hangs in folds upon the trunk and limbs, and 
is dull and dirty in its tint, the eyes become sunken and surrounded with 
bluish circles, and the whole appearance of the child is that of misery and 
exhaustion. 

In infants, it is very common to meet with erythema of the buttocks and 
thighs, produced by the contact of the acrid stools and urine with those 
parts. This symptom is said by Bouchut to exist in five-sixths of the 
cases. We feel quite sure that it does not exist in so large a proportion of 
those which occur in private practice, though we have met with it in nu- 
merous instances. When severe it is generally accompanied by papules, 
which ulcerate after a time and form superficial ulcerations upon the skin. 
The.e ulcerations sometimes run together, and become of considerable size 
and depth; In the form of the disease met with in the children's hospitals 



SYMPTOMS — DURATION. 397 

ill Paris, ervthema ami ulcerations of the heels and internal malleoli are 
also met with, and constitute a serious complication in the case. They are 
said to de}>end on want of cleanliness, and the rubbing together of the feet 
of the child, unprotected by covering. We have never met with them in 
private practice. 

The duration of the disease is stated by the French writers to be gener- 
ally about fifteen days, at the end of which time convalescence is usually 
established. It may be shorter or longer. According to our own experi- 
ence it is entirely uncertain. Most of the cases that have come under our 
notice have been rather shorter. The disease subsides gradually. The 
number of stools diminishes; they become less abundant and more con- 
sistent, and return to their natural color and odor; the pain on pressure, 
and the enlargement and tension of the abdomen disappear ; and as this 
occurs, the fever subsides, the appetite returns, the temper improves, and 
the child enters into full convalescence. 

The chronic form of entero-colitis generally follows the acute, though it 
sometimes presents many characteristic features from the fii-st. It differs 
from the acute form chiefly in the absence or the much slighter degree of 
fever and other constitutional symptoms in the early stage. The diarrhoea 
is less abundant and less frequent. At first the child retains its spirits and 
many of the signs of health. But gradually its strength fails, the temper 
becomes irritable, the complexion grows dark, sallow, and unhealthy, the 
skin becomes dry and harsh, and, in consequence of the emaciation which 
takes place progressively with the other symptoms, hangs in folds around 
the shrunken extremities, or is drawn tightly over the joints and other 
osseous protuberances. The tongue is generally moist and natural, though 
in some cases red and dry, whilst in others it, together with the lips, par- 
takes of the pallor which pervades all parts of the body. The abdomen 
is usually distended and sonorous on percussion, and may be painful or 
not on pressure in ditfereut cases, or in the same case at different periods of 
the di."^a*e; it^^ parietes sometimes offer no resistance to the touch, so that 
the intestinal convolutions may be readily felt by the hand, or even be- 
tween the fingers ; and in some cases we have seen them so thin and re- 
laxed, though the abdomen was more prominent than natural, that the 
outlines of the intestines, and even their peristaltic movement, were visible 
upon the exterior. The appetite generally persists in spite of the gravity 
of the disea.«€, and is sometimes increa.sed. The stools, as has been stated, 
are not .«o frec|uent as in the acute form, .seldom numbering over six or ten 
in the day and night. They consist of the products f)f an imjierfect diges- 
tion, and contain not unfrequentiy the alimentary substances in the state 
in which they were swallowed, mixed with mucus, serum, pus, and some- 
times blood. Their consistence varies constantly, but they are usually 
semifluid. Their odor is .seltlom natural, and often extremely offen.-ive. 

The cowrie of the disea.se is very irregular. Kven in the worst and most 
prolonged cases intermi.ssions or remi.-wions occur, so that the child will 
often improve greatly for days or weeks, and then suddenly relapse into 
as bad a condition as ever. In favorable cases these remissions become 
more and more frequent, and the symptoms gradually improve, until at 



398 ENTERO-COLITIS. 

length the child is restored to health. In fatal cases death is occasioned 
by the utter deterioration of the general health which finally occurs, and 
the child perishes, worn out by long illness, or, as more frequently happens, 
some complication arises which hurries on the fatal event. Thrush is a 
frequent complication of chronic eutero-colitis, and doubtless often hastens 
the death by the impediment which it occasions to the nursing or feeding 
of the child. Vomiting has almost always occurred towards the close of 
the fatal cases that we have seen, especially in those in which extensive 
thrush was present. 

The duration of this form is of course very uncertain. It may last for 
weeks or months. We have known it to last two and three months in sev- 
eral cases, and in two others it lasted with occasional intermissions, in one 
a year, and in the other eighteen months. 

Diagnosis. — The diagnosis of acute entero-colitis is not difficult. There 
is no disease with which it is likely to be confounded. The characteristic 
features of the malady are the diarrhoea and other abdominal symptoms, 
and the absence of signs of other disease. The secondary cases are distin- 
guished by the occurrence of the usual symptoms of entero-colitis during 
the progress of the primary malady. 

The chronic form is not likely to be mistaken for any other disorder, 
unless it be the diarrhoea which occurs in tubercular disease, from which it 
is to be distinguished by the presence in the latter of the signs of tubercu- 
losis of other organs. 

Prognosis. — Acute entero-colitis is always a serious disease in infants. 
The prognosis will depend in great measure on the circumstances under 
which the affection has been developed. It is much more unfavorable in 
a child fed on artificial diet, either wholly or in part, than in one who is 
nursed at a fine breast of milk. It is more unfavorable also in weak and 
delicate than in robust and vigorous children, and in those of poor people, 
who live in crowded and unhealthy portions of cities and towns, whose 
habitations are small, damp, and ill-ventilated, and whose food is coarse 
and insufficient, or improper, than in those placed in more fortunate and 
more healthful hygienic conditions. It is a more dangerous disease in 
summer than in winter. In hospitals for children it is a very fatal dis- 
order, owing to the bad hygienic conditions under which the inmates are 
placed. In children who have passed through the first dentition, the prog- 
nosis is, as a rule, favorable. The disease is seldom dangerous in such 
cases when it occurs as a primary affection, while, as a secondary affection, 
on the contrary, it is much more apt to be serious. 

The unfavorable symptoms are : great frequency of the stoels ; collapse ; 
violent vomiting or retching ; and dangerous cerebral symptoms, as coma, 
rigidity of the limbs, paralysis, or convulsions. 

Treatment. — The prophylactic treatment is very important. It includes 
attention to habitation, diet, dress, and exercise. The most frequent causes 
of entero-colitis are high summer temperatures, residence in an unhealthy 
locality, and improper diet. A child may have been born of the most 
healthy parents; ma}'' be living, if an infant, on the most healthy food in 
the world, the milk of a perfectly sound woman, or, if it have been weaned, 



PROPHYLACTIC TREATMENT. 399 

on the best possible substitute for breast-milk, one selected by the most 
consummate medical art; and yet, if it be the unfortunate resident of some 
low, crowded, and unclean part of any of our cities in the summer season, 
it has but small chance of escaping inflammatory diarrho?a or cholera in- 
fantum, to be followed by chronic diarrhcra. Or, a child may be living in 
the best part of these cities, with every advantage that wealth and the 
medical art can give, and, if in the period of the first dentition, and the 
summer heats be great, it will be only too apt to have some form of the 
disease we are considering. Under the latter circumstances, its chance of 
escaping the disease will be vastly greater than under the first-named con- 
ditions, but the true prophylaxis is, where the parents are so situated as to 
be able to do that which is best for the child, removal from the city during' 
the hot season (from the early part of June to the last week of September) 
into some cool and healthy region of country. We have long thought that 
the best region to spend the summer in is a somewhat high and cool part 
of the country, where the breezes have full sweep, and where the topography 
is such that water runs off rapidly, or sinks fast into the soil. The seaside, 
if it be a point where there are no marshes and no malaria, and where the 
supply of milk and other wholesome food is abundant, is an excellent 
place. We have seen more remarkable sudden efi^ects from the removal 
of a dangerously sick child to the seaside, than from a change to the in- 
terior; but, nevertheless, for a continued residence of three months, we 
prefer a high interior locality. 

On the other hand, if a child be placed in the most favorable possible 
condition as to locality, and the diet be a radically bad one, a deficient or 
unhealthy breast, improper artificial diet, or a foolish allowance on the 
part of the mother or nurse to the child of a variety of vegetables, of fruits, 
and especially of berries like currants or gooseberries (and we have known 
such things;, it can scarcely escape the penalty of a fit of illness more or 
less severe. 

A child who is so unfortunate as to get a sharp attack of entero-colitis 
in June or July, is very apt to continue more or less sick during the rest 
of the summer, so that the true prophylaxis is to take it away from the 
city early in June to avoid this danger, and not to return until after the 
September heat«< are over. 

As the reasons for decisive medical action in any disorder cannot l)e too 
strongly demonstrated, and as this suiyect of removal is a very important 
one, we think it well to advert here to the results of experience in this 
matter in the diarrhrea and dysentery of our armies during the late war. 
Here we have. the experience of intelligent army medical officers in vast 
numbers of cases, — cases. Uh), so grouped together as to give opportunity 
for the most accurate observation. In the S<mHary Memoirn of the Wtir 
of the Rebellion J colUded and puhlij<fwd hy the Uniied SUdes Sanitary Com- 
miAjtion (Chapter VII, Camp Diarrhtra and DyMnntery, by Sanford B. 
Hunt, M.D., p. 291), will be found a most valual)le essay on the causes 
and treatment of diarrhrea and dysentery, which no one can read without 
being impressed with the similarity (saving the ages of the patients) of 
those diseases to the one we are describing. At page .304, Dr. Hunt 



400 ENTERO-COLITIS. 

says : " But in others the disease progressed, became follicular, and finally 
ulcerative. In the treatment of these, great difficulty was experienced, 
from the fact that the patient was still exposed to the causes of this 
malady ; and it came to be a fixed doctrine at Southern and Southwestern 
stations that confirmed cases had no security for cure except by removal 
to the North. This soon became a governmental policy, and hospitals 
were established in New England, along the Lakes, and in the Northwest, 
to which chronic cases were sent in great numbers. Among patients not 
thus removed, but treated in Southern hospitals, much vacillation and 
irresolution were exhibited in the prescriptions of surgeons, as happens in 
all diseases, the treatment of which by drugs is usually unsuccessful. To 
trace the history of an individual case was to find that the prescriber had 
run the round of all remedies, from opium to astringents, from astringents 
to quinine, from quinine to bismuth, and from bismuth to nux vomica, 
from nux vomica to mercurials, returning almost alwaj^s to opium as the 
drug, which at least alleviated, if it did not cure." 

The dress ought to be suited to the weather. It is best to keep on the 
child, even in hot weather, a very thin and soft flannel shirt, with short 
sleeves. This should never be removed. A young infant should wear all 
summer long a thin and light flannel petticoat. A child a year old may 
may have the flannel petticoat removed for a few days when the tem- 
perature rises to above 85^ or 90"^, when it suffers evidently from the heat ; 
but so soon as the temperature falls to 85° or below, the petticoat should 
be replaced. This happens only for a few days in our summer season, and 
the change should be made with great care, and only under the supervision 
of an intelligent and watchful mother or nurse. 

Exposure to the open air is another point in the prophylactic treatment 
which is of great importance. In country houses in the summer, a young 
infant may get nearly as much air as it needs, but in cities the air of houses 
is much more dull and stagnant, and the child ought to be carried out into 
the streets and squares for several hours morning and evening. If possible, 
it should be taken to drive into the open country. Short excursions, by 
rail or boat, for the children of the poor, who cannot escape from the city 
in summer, are very useful in carrying the child safely through the summer. 
But in ail such jaunts after health, the parents should so arrange matters 
that the child shall be as little fatigued as possible. The best plan is to 
go in the morning and return in the evening, resting through the middle 
of the day at some point where the child can take rest and midday sleep, 
which are quite as important as fresh air. Included in this subject is 
that of exercise. This becomes very important when the child is old 
enough to walk and run, for then an ignorant or thoughtless woman might 
think the more exercise the better, whereas it is necessary to watch such 
children very carefully, since, if they are allowed or enticed to take undue 
exercise, the resulting fatigue becomes a positive cause of diarrhoea. A 
child of two or three years old should never be induced to take long and 
continuous walks ; it ought to frisk and play, not walk straight ahead, like 
a man in training ; for that kind of exercise, we have remarked, never suits 
children well. 



THERAPEUTICAL TREATMENT. 401 

It has already been stated that one of the most frequent causes of the 
malady is the attempt to bring up the child on artificial diet, and particu- 
larly ou one of an improj>er kind. It is clear, therefore, that to avoid the 
disease it is necessary that the child should, if possible, be nursed. If this 
cannot be done, the diet ought to be wisely selected and regulate<l in all its 
details by the physician. The one most proper is evidently that which most 
closely resembles the natural aliment of the infant. For directions as to 
diet, we must refer the reader to the remarks upon diet, where we have 
discussed this point quite fully. 

Diet in the Attack. — After the disease has made its appearance, the diet 
should be very carefully regulated. This constitutes, in truth, the most 
irapi^rtant point in the treatment. If the child is nursing, it ought to be 
confined entirely to the breast, and should the nurse have a large quantity 
of milk, and the stools exhibit considerable quantities of undigested casein, 
it must be somewhat restricted as to the frequency and length of time it is 
allowed to nurse; in other words, it must be moderately dieted for two or 
three days. Should there be the least suspicion that the milk of the nurse 
is unhealthy, it ought to be examined as before directed, and, if found un- 
healthy in any respect, a new nurse must be provided. If the disease 
comes on shortly after weaning, and persists for several days in spite of 
careful diet and treatment, it is safest to restore the child to the breast. 
When this cannot be done, we must select that form of artificial diet 
which seems most suitable. The best is, in our opinion, the cow's milk 
prepared with the solution of gelatin in the manner already recommended, 
but made very weak for a few days. We have often found it necessary, 
under these circumstances, to add four and even more parts of water to 
the milk, instead of two or equal parts, as is the usual custom. 

In older children the diet, for a few days, ought to consist of simple 
milk and water, or of thin preparations of arrowroot, rice flour, sago, 
tapioca, or wheat flour, made with milk, or milk and water, with small 
quantities of bread, or, if the child refuse such articles, panada, or light 
chicken- or mutton-water may be allowed. The quantity of food, what- 
ever it be, must be determined very much by the child's instincts. When 
the appetite continues, we can seldom go wrong in allowing jis much of 
tbe^e eimple foods as the patient will take. Still, the physician ought to 
know accurately the amounts that are given, and if he finds the patient 
taking a full healthy average, or more, it will be best to restrict the quan- 
tity somewhat, and ofler water frequently, on the supposition that the little 
patient is taking ius liquid food more from thirst than hunger; or else in- 
crease the water of the fixxl, if he have reason to believe that the .solid 
matter is in too large a pro|>ortion. 

Therapei'TIcal Tkeatmext. — We liave found a large number of the 
mild ca.«es that have come under our notice to recover under very simple 
tn ainif nt. When the patient is an infant at the breast, before the period 
ot d» iitilion, the f^iraple direction not to allow it to nurse as much as u.^ual ; 
the use of a warm bath morning and evening, if the skin be heated and 
the child restlese and fretful ; the administraticm of a small dose of castor 
oil thalf a teaspoonful to a tea.«poonful;, or of spiced syrup of rhubarb in 



402 ENTERO-COLITIS. 

the same quantity, with a half drop to a drop of laudanum, at the begin- 
ning of the attack, to remove any undigested food that may be lying in 
the bowels, followed in one or two days, if the disorder continues, by 
some simple astringent remedy, generally suffices to effect a cure. When, 
on the contrary, the case depends on an unhealthy or insufficient milk, 
when the child subsists entirely on artificial food, and when the disease 
coincides with the process of dentition, the attack is kept up and aggra- 
vated by these causes, and it is more difficult to obtain a cure. In the 
former case the diet is, of .course, of all importance; in the latter the 
gums must be carefully examined, and if found to be swelled and in- 
flamed, and the teeth near the surface, they should be freely incised. 
After these matters have been attended to, the kind of treatment will de- 
pend on the character of the general symptoms and the violence of the 
enteritic disorder. 

When the pain is violent, the discharges frequent, painful, and mixed 
with mucus, muco-pus, or blood, and the abdomen tense and painful to the 
touch, moderate local depletion by leeches may be used with advantage and 
safety in vigorous children. The leeches are best applied over the lower 
part of the abdomen. About six or eight American leeches, or two for- 
eign ones, may be applied at the age of one or two years, so as to take 
about two ounces of blood. Of late years, however, we have not em- 
ployed depletion so much as formerly, but use instead warm baths, poul- 
tices to the abdomen, or warm stupes, and refrigerant medicines. Small 
doses of the sulphate of magnesia and laudanum are very useful ; or we 
may employ spirit of nitrous ether, or solution of the acetate of ammonia 
with paregoric or laudanum, or the following mixture : 

R. 



-Sodse Bicarb., . 


. 


. ^ss. 


Mass. Hydrarg., 
Tr. Opii Camph., 
Syrup. Simp., . 
Aq. Menth., 


. 


. gr. iij. 

. gtt. L vel f^j 

. f^xiv.-M. 


Dose, a teaspoor 


ifiil every three oi 


four hours. 



The warm bath, used at a temperature of 95° to 97°, twice or thrice a 
day, is most excellent. It is a good plan to wrap the child, immediately 
on being taken out of the bath, in a warm muslin sheet, and over this a 
light blanket, and let it lie on the lap or bed for twenty minutes or half 
an hour. During the past two years, the external use of cold water in 
febrile diseases has been extended widely, and among the affections in 
which it has been applied are entero-colitis and cholera infantum. We 
have ourselves limited the use of water to tepid bathing or cool sponging 
when the temperature was considerably elevated ; but excellent results 
have been obtained by some observers, both here and in Europe, by the 
use of cold baths (72° to 78° Fahr.), repeated several times during the 
day when the febrile temperature rose to 103° or 104°. If the temperature 
should remain elevated, despite the use of repeated cool spongings and the 
warm bath, the cool baths may be tried, though we should not recommend 
them quite so cold as above mentioned. 



THERAPEUTICAL TREATMENT — CALOMEL. 403 

The hot poultice or stupe recommended above should be covered with 
oiled silk, secured by a towel pinned around the body, changed every 
three or four hours, and kept on for the greater part of the day, or for 
several days. 

Calomel has been so highly recommended and so long employed in these 
cases, thai we feel some hesitation in saying how often it has disappointed 
us. Certainly we have found in many children that it was of no evident 
use, and in the old-fashioned doses of a grain or half a grain, we think it 
only adds to the irritation of the bowels, Jn doses of the twelfth and 
eighth of a grain, with chalk and opium, every two or three hours, we 
formerly thought it was sometimes useful, but we cannot resist the im- 
pression which years have given us, that the useful agents in these instances 
have been the chalk and opium, and especially the opium. 

We still have conlidence in, and employ, the mixture of blue mass and 
soda above recommended. It does not irritate, as we have known the 
larger doses of calomel to do ; but, on the contrary, when given for thirt)''- 
six or forty-eight hours, under the circumstances mentioned, it is frequently 
followed by an improvement in both the number and character of the 
stools. 

Before quitting this question of the use of mercurials in diarrhoea, we 
wish to quote the results at which some of the more modern observers have 
arrived, with the remark, as we pass on, that our own conclusions were much 
the same ten years ago as those expressed above. We shall do this even 
at the risk of being tedious, for we think the point a very important one. 
In the first place, we shall quote the opinion of one of the ablest of the 
United States army surgeons, as to the use of this drug during the late 
war. The writer ( Outlines of the Camp Diseases of the United States Armies 
as observed during the Present War, by J. J. Woodward, M.D., Philadel- 
phia, 1863), in the article on Chronic Diarrhoea, a disorder closely akin 
in many of its symptoms and anatomical lesions to the entero-colitis of 
children, says, at page 262: "Among the remedies liberally employed in 
chronic diarrhoea is one which can only be mentioneol with disapprobation. 
This is the mercurials, which are too frequently administered to gentle 
salivation in the form of blue pill or calomel, combined with opium and 
ipecacuanha. The authority of some of the most distinguished American 
medical writers is in favor of the employment of mercurials in the chronic 
diarrhoea of civil life; yet when it is remembered that even those modern 
writers, who most warmly advocate their general emplojyment in the treat- 
ment of inflammation, recommend them to be discontinued as injurious 
whenever the pro)cess has gone on to ulceration, it would appear that even 
sound mercurialists would avoid using them in the form of chronic diar- 
rhoea which is mo»st common in the army. 

" Practically it will be founol that although in some cases mercurials may 
succeed, a.s much less dangerous remedies would have done, in cho'cking 
the progress of the disease, yet that in the majority of cases their employ- 
ment is accompanieol by an increa>e of the debility, the lo)ss of appetite, 
the ansemia, and the general constitutional symptoms, without any dimin- 



404 ENTERO-COLITIS. 

ution in the frequency of the stools. They are, therefore, to be regarded 
as dangerous and inefficient, and their use in these cases has been com- 
pletely abandoned by those surgeons who are most successful in the treat- 
ment of the disease." 

Dr. T. K. Chambers, of London (^Clinical Medicine, Loudon, 1864, p. 
517), in considering the treatment of diarrhoea in which the stools exhibit 
the products of acute inflammation, says: " The drugs I have most trust 
in are calomel, ipecacuanha, and carbonate of soda. Of the first and 
second equal quantities, and.a double quantity of the third, may be made 
into powders, of which from four to six grains, according to the child's age, 
may be given every three hours. This is a traditionary powder, but it is 
right to say that I have in a good many instances lately left out the 
calomel, and the case has done just as well, if not better, without it." 

Dr. J. L. Smith, of New York {op. cit, p. 379), says nothing whatever 
about mercurials in his article on the treatment of inflammatory diarrhoea, 
from which we are led to suppose that he does not use them. He however 
quotes Dr. E. H. Parker as giving, when the condition approaches that of 
dysentery, a mixture consisting of about ten grains of blue mass rubbed up 
in two drachms of syrup of rhubarb, to which is added one half teaspoon- 
ful of paregoric, and four ounces of chalk mixture. Of this the dose is a 
teaspoonful every two or three hours. Dr. Parker says that the " blue mass 
certainly does not act like the calomel, not producing in purgative doses so 
great prostration, and in small doses it does not lessen the proportion of 
fibrin in the blood, as is the case with calomel." Dr. Smith's comment on 
this is : "I have never used this mixture, having been generally satisfied 
with the effects of the castor-oil mixture." 

It is unnecessary to say any more upon the use of mercurials, and espe- 
cially of calomel. We have quoted enough to show that our own opinions 
find us in very good company. 

We regard opium as one of the most valuable remedies we have in the 
treatment of this disease. In a former edition of this work it was stated 
that some writers objected to its employment in the early stage as injuri- 
ous, but that we had not been deterred from using it, except in cases pre- 
senting manifest signs of cerebral irritation in connection with the febrile 
symptoms ; but that when there has been nothing more than irritability, 
restlessness, and insomnia, when there was evident pain during the dis- 
charges, and when the latter have been very frequent, we had always made 
use of some of its preparations without hesitation, and certainly without 
injury, but, on the contrary, with very great benefit. Our longer experi- 
ence confirms us in this view and practice. The propriety of using large 
doses of opium in the early stages of cholera infantum may well be ques- 
tioned, as it has come to be by some of the best observers in Asiatic cholera ; 
but this matter will be considered under the head of that disease. In the 
disorder under consideration, which is one of an inflammatory catarrhal 
type, we have never seen the moderate use of opium do anything but good. 
When the nervous symptoms are very marked, if they be of the kind which 
denotes disturbance of the reflex functions of the nervous system rather 



THERAPEUTICAL TREATMENT. 405 

than those indicating cerebral disorder, we find nothing which answers so 
well our purpose as this remedy. When, however, there is unusual quiet, 
tending towards drowsiness or stupor, with contraction of the pupils, we 
make use of it only with great caution and in very small doses. We are 
glad to find that Dr. Stokes also" employs opium without hesitiition. He 
says, "It is a remedy that requires caution in its exhibition, but one of 
great utility." It generally lessens the number of discharges, and very 
often diminishes the heat of skin and frequency of the circulation, by al- 
laying the irritability of the nervous system, while at the same time it 
greatly promotes the comfort of the child. We have used it in the form 
of laudanum or paregoric, given in combination with a laxative early in 
the case, or by enema, and afterwards in that of the Dover's powder or 
powdered opium. For a child under six months old half a drop of lauda- 
num is enough to give by the mouth. Of the Dover's powder about a 
sixth or eighth of a grain may be administered mixed with two grains of 
chalk, to be repeated every two or three hours, until three or four doses 
have been taken, or until the child shows some degree of drowsiness from 
the action of the opium, after which it ought to be suspended for six or 
eight hours, and then resumed. Or the opium may be given in the form 
of laudanum combined with the sulphate of magnesia as recommended 
above. The old-fashioned castor-oil emulsion, in the proportion of one 
drachm in a one or two-ounce mixture, with half a drop of the deodorized 
laudanum to each teaspoonful of the mixture, is often very soothing and 
beneficial. When there is marked tenesmus, with frequent small evacua- 
tions, opium may also be used with great advantage by the rectum, either 
to the exclusion of any in the mixture, or in addition to that, taking care 
to graduate the quantity by the degree of drowsiness that maybe induced. 
At one year two drops in one or two teaspoonfuls of water or thin starch- 
water may be used two or three times a day. In such cases, suppositories 
are sometimes retained better than enemata. A twelfth to a sixth of a 
grain of powdered opium, made up with cocoa butter, may be given instead 
of the injection. 

Generally speaking the acute constitutional symptoms either subside or 
disappear under the above treatment, and very often the (liarrh<L'a also 
ceases and the child recovers. When, however, the diarrhcea persists, it 
is necessary to resort to two other classes of remedies, upon which great re- 
liance is placed in the treatment of this affection. These are antruigents 
and nbmrbenU, of which the most important are prepared chalk, powdered 
crab's-eyes, bi-smuth, acetate of lead, rhatany, kino, and catechu. The 
chalk may be used in the form of the officinal mistura cretui, a teaspoon- 
ful of which is given afler each loose evacuation, or several times a day. 
When the ca.«e is severe, the efficacy of this remedy is much increased by 
the addition of tincture of krameria, in the pr(»[)ortion of a drachm to two 
or three ounces of the mixture, of some opiate preparation, or of ten or 
fifleen drops of the aromatic syrup nf galls (to be described presently) to 
each teaspoonful. Chalk may be usefl also with great advantage, its stated 
above, in powder, combined with Dover's powder. 

The powdered crab's-eyeJi will sometimes arrest ca-ses in which prepared 



406 ENTERO-COLITIS. 

chalk fails to produce any effect. It is generally employed in mixture. 
The formula we employ is the following : 

R- — Ocul. Cancror. P»lv., . . . . . • HJ- 



3y. 

f3iss.— M. 



Pulv. Acacise, ....... 

Sacch. Alb., 

Aquae Fontis, Aquae Cinnamom., aa 

A teaspoonful to be given four,, five, or six times a day. 

M. Bouchut recommends the following prescription of Hufeland's : 

R. — Ocul. Cancror. Pulv., gr. x. 

Aquae Fceniculi, Syrup. Ehoi, aa . . . f^ss. — M. 

Give a teaspoonful every hour. 

Suhnitrate of bismuth has been highly recommended, for a number of 
years past, as a remedy in diarrhoea. Dr. Woodward (op. cit, p. 258) 
quotes Assistant-Surgeon Dr. John B. Trask, U.S.A., as lauding it very 
highly in the chronic diarrhoea of the armies during the late war, and in 
California and Oregon, especially in those cases in which there is nausea 
or other disorder of the stomach. Dr. Woodward states that " he has given 
it a fair trial, and while he is far from regarding it as a specific, believes 
it to be a most valuable article in both simple, irritative, and in chronic 
diarrhoea." Dr. Trask prefei*s to give the whole quantity for the day in a 
single dose ; but Dr. Woodward states that this view does not correspond 
^vith the general experience on the subject. It may be given in doses of 
one to two grains, to children one year old, every two or three hours. It 
can be administered in powder with sugar alone, or combined with pre- 
pared chalk, or in mixture with simple syrup, or ginger or acacia syrup, and 
some aromatic water. We have employed it quite frequently, but, on the 
whole, have not found it so effective as we had been led to hope. 

Acetate of lead has been highly extolled by many writers in the treat- 
ment of the diarrhoeas of children. We have had but little experience in 
its use, and are, therefore, unable to oflTer an opinion in regard to the influ- 
ence which it may exert. It may be given in doses of from a sixth to an 
eig*hth of a grain, alone, or combined with chalk or Dover's powder, every 
two hours. Krameria, kino, and catechu may be exhibited alone, in the 
form of infusion or solution, or they may be given in conjunction with the 
chalk mixture. We have frequently employed the tincture of krameria in 
the latter way, and believe it adds very much to the efficacy of the remedy. 
About one or two drachms may be added to two ounces of the mixture, and 
the usual dose given. We have used, with much advantage, either alone 
or with chalk or crab's-eyes mixture, an aromatic syrup of galls, in the dose 
of from fifteen to forty drops three or four times a day, or, when the dis 
charges are very frequent, every two or three hours. It is prepared accord 
ing to the following formula : 

R.— Gallae Opt. Pulv., ,^ss. 

CMnnamom. Pulv., . . . . . • ^y- 

Zingib. Pulv., gss. 

Spts. Vini Gall. Opt., . . . . . . Oss.~M. 

Let tbe ingredients stand in a warm place for two hours, and then burn off the 
brandy, holding some lumps of sugar in the flames. Strain through blotting- 
paper. 



4 



THERAPEUTICAL TREATMENT. 407 

Dr. Eberle {loc. cit., p. 221") highly recommomis the root of the cjcraniiini 
inacuhfum. He says it makes an "agreeable and efficient astringent," 
and is less apt to derange the digestive organs, and occasion irritation of 
the mucous membrane of the bowels, than kino. He uses it in the form 
of a decoction made with milk, by boiling an ounce of the fresh root in a 
pint of milk until half is evaporated. The dose is from a teaspoonful to a 
tablespoonful four or five times a day, according to the age of the patient. 

The nitrate of silver is highly recommended as a remedy of late years by 
several writers. It is given both internally and by enema. The modes of 
administration will be described in the remarks on the treatment of the 
chronic form of the disease. 

Revulsives are often of much service in the treatment of this, as of al- 
most all the diseases of childhood. When there is much restlessness and 
irritability, with heat of the head and trunk, and coolness of the extremi- 
ties, it will be found that mustard foot-baths or sinapisms to the extremities, 
often allay these symptoms, and greatly comfort the little patient. When 
the abdomen is tense and painful, and the discharges preceded or accom- 
panied by movements or crying indicative of pain, the application of a 
poultice of mush and mustard from time to time, to be followed by a sim- 
ple mush poultice, sometimes acts very usefully. 

Tonif's and stijnulauts are often necessary in weak and delicate children 
from an early period in the attack, and in those who are stronger, after the 
disease has lasted for some time, and the acute symptoms have ceased, and 
been followed by weakness and exhaustion. The best tonic is, probably, 
snlpJiate of quinine, in doses of from a quarter of a grain to a grain three 
times a day, continued for one, two, or three weeks if necessary. Old brandy 
has answered better in our hands as a stimulant, than wine, wine-whey, or 
any of the tinctures. It may be given to the youngest children in doses of 
from five to ten drops every two hours, or a teaspoonful may be added to a 
wineglassful of sweetened water, and a teaspoonful given whenever the 
child will take it. We have been obliged, in several cases, to continue 
the use of the brandy for three, four, and five weeks. At the time when 
we are obliged to resort to this class of remedies, it is almost always nec- 
essary also to pay attention to the improvement of the diet. The propor- 
tion of milk to water ought to be increased, if it has been small heretofore; 
and we should employ every means to induce the child to take a sufficient 
quantity without overloading the stomach. At this stage small quantities 
of animal broths are proper, or the child may be allowed to suck pieces of 
juicy meat, or to eat very finely minced meat of chicken or mutton. The 
diet is in fact a most important part of the treatment at this period. Dr. 
8tokes says of it, that " many children are lost by the practitioner neglect- 
ing this p<iint." 

Occasionally, indeed quite frequently, vomiting becomes a most trouble- 
some symptom in entero-colitis. When it occurs at rare intervals, and 
without much distress to the patient, it needs no attention, since it is to be 
supposed that the physician has already arranged the hygienic and thera- 
peutical treatment so as to suit the ordinary conditions of the disorder. 
But when vomiting becomes frequent and violent, so that the child rejects 



408 ENTERO-COLITIS. 

a large proportion of all that is given to it, and when, between the acts of 
vomiting, the little thing refuses almost everything that is brought to it, 
all its usual foods, medicines, and sometimes even water, it is evident that 
the child has a more or less positive sense of nausea which causes loathing 
of food, and the symptom becomes a serious complication which requires 
special attention and treatment. In such cases, there is no use in forcing 
food or drugs which it loathes upon the child, unless all other means have 
failed, when of course, we must attempt to make it take concentrated foods 
in small doses. The better plan, at first, is to change the diet in toto — to 
abandon milk and all its preparations for two or three days, if these excite 
disgust — and give light beef or chicken tea, just touched with salt, or raw 
beef, or, if this also is refused, cold extract of beef in one or two table- 
spoonful or wineglassful quantities, or pieces of juicy and rich beef very 
slightly cooked, to be sucked. Or we may try small portions of yelk of 
egg, hard boiled, or what we have often found was eagerly taken in such 
conditions, wine-whey, of which we have given, in the second year of life, 
as much as a tumblerful in twenty-four hours, and this without the slight- 
est effect of undue stimulation, febrile heat, or excitement. Sometimes, 
when the child refuses its ordinary milk persistently, or vomits it so soon 
as taken, it will drink willingly, and retain very well, lime-water and milk, 
in the proportion of one of the former to two or three of the latter, with 
just enough brandy to change the taste. We know that some medical 
men object entirely to the use of stimuli in children on two grounds : 
1. That alcohol has no remedial power whatever, or that it is positively 
injurious in all cases. 2. That its use tends to produce that pernicious 
taste for stimulants which engenders the habit of drunkenness. To the 
first objection we can only reply that our observation and experience have 
led us to a different conclusion, and that, when employed in certain condi- 
tions of the vital powers, which we have carefully endeavored to describe, 
stimuli are of the highest value as a therapeutic means. To the second 
we reply that we have never, so far as very careful observation goes, pro- 
duced a drunkard by any use we have made of them. We agree that 
physicians ought to be very careful not to employ them in any attractive 
form, as a long-continued remedy, in children over six or eight years of 
age. When we desire to use any form of alcohol in a chronic case in 
children over the age mentioned, we always give some of the bitter tinc- 
tures or elixirs. When possible, we always order the oldest and most deli- 
cate braudy that can be procured. As to the quantity, this must depend 
on the age of the patient, the instinct and idiosyncrasy of the child, and 
the degree of severity of the case. At the age of six months, from ten to 
fifteen drops may be given every two or three hours in two or three ounces 
of the lime-water and milk ; and at one and two years, from twenty to 
twenty-five drops in from four to six ounces of the milk food every two, 
three, or four hours. It may be a sign of the old Adam in the poor little 
sufferer, but we have often known children to take, for days together, milk 
with brandy in it, who would not touch the milk without this addition. 
We cannot but think that in such cases it is an instinct for a useful agent, 
like the appetite of patients in typhoid or typhus fever, in certain of their 



II 



TREATMENT OF THE CHRONIC FORM. 409 

phases, for wine or brandy, which disappears when the necessity for it 
passes away, as has been so well described by Dr. Corrigan, of Dublin, in 
his able little essay on the treatment of Irish typhus. 

Under these circumstances, all medicines which disgust the child must 
be laid aside. A bitter, or nauseous, or gritty dose will, in such states, 
surely cause vomiting, as will, in older persons, under such conditions, an 
odor or taste, or even an idea. We have seen a little infant, sick with 
diarrhiva, who was sitting languidly upon the floor, made to gag and 
retch, by chancing to pick from the floor a piece of softened bread. The 
impression produced upon the tactile sense of the fingers by the wet and 
mushy substance caused sickness at once, as the filing of a saw sets the 
teeth of a delicate nature on edge, and brings water into the mouth. All 
offensive and bitter doses must be abandoned therefore. AVe have often 
used, in such cases, the following prescription with much benefit : 

R. — Liq M<>rph. Siilphat., ..... frtjxxxij. 

Acid.Sulph Dil., Ttjjxv. 

CursiQoa, f:^!]. 

Aquae, ........ f^xiv. — M. 

Dose, a teaspoonful every hour or two hours, at the age of six months to a 3'ear. 

For older children, the proportions of the opiate and acid must be in- 
creased. When the nausea subsides or passes away, or when the child 
becomes drowsy, the intervals between the doses must be lengthened, and 
as the symptoms disappear, the other remedies necessary for the diarrhoea 
may be resumed, and so too of the food. Dr. J. L. Smith, of New York, 
states that the best remedy he has used for vomiting is the neutral mix- 
ture, as follows: 

H- — Potass. Bicarbonat., gr. xxv. 

Acid. Citrir., i^r. xvij. 

Aquae Amygd. A mar., f^j. 

Aquae, f5ii. — M. 

One teaspoonful to a child from eii^ht to twelve months old, repeated according 
to the nau-iCH or vomiting. 

Creasote is also sometimes very useful. Dr. Smith says that in the 
Nursery and Children's Hospital of New York, this remedy is used, given 
in the proportion of an eighth of a drop in a teaspoonful of lime-water, in 
a tea«[K>onful of milk or breast-milk, and has been found successful in a 
certain proportion of cases. 

Thkatment of Chronic ENTEUO-foLiTi.s. — The management of the 
hygiene of the patient is more important than any other part of the treat- 
ment, in this, as in nearly all the diseases of the digestive organs in chil- 
dren ; for cases will often recover when the diet, drinks, and exercise are 
properly regulated, without the use of any drugs whatever, whereas, most 
assuredly, but a small proportion of them would terminate favorably under 
the best and wisest therapeutical me<]ication, were the hygiene of the child 
neglected. The remarks that have been made as to the diet most proper 
in the acute form will apply here. If the child have been weaned only a 



410 ENTERO-COLITIS. 

few weeks before the time at which we are consulted, and the case is at all 
serious, it is better to advise the procuring of a wet-nurse. We have 
several times known cases of the disease which had resisted the most care- 
fully managed artificial diet and therapeutical treatment, recover in a few 
days after the child had been restored to the breast. It is often, however, 
impossible to follow this course, from the refusal of the parents to obtain a 
nurse, or of the child to take the breast of a stranger, and we are obliged 
to rest content with artificial food. We believe that the kind of diet which 
suits the largest number of children is one of milk. During a number of 
years past, we have found the gelatin food, already described, to answer 
better than any that we have ever essayed. It ought to be made very 
light and thin. About a scruple of gelatin should be dissolved by boiling 
in half a pint of water. Towards the end of the boiling, a gill of cow's 
milk, and a teaspoonful of arrowroot made into a paste with cold water, 
are to be stirred into the solution, and from one to two tablespoon fuls of 
cream added just at the termination of the cooking. It is then to be 
sweetened moderately with white sugar, when it is ready for use. The 
whole preparation should occupy about fifteen minutes. 

When cow's milk, mixed with water alone, or prepared in the manner 
just recommended, evidently disagrees, we have sometimes found cream 
with water alone, or better still, with the solution of gelatin in water, in 
the proportion of one part of cream to five or six of the latter, to suit very 
well. In other cases very carefully prepared beef tea or chicken or mut- 
ton water, given several times a day or but once, according to the taste 
and fancy of the child, will answer better. It sometimes happens that the 
child will refuse everything that has been mentioned, and yet the prostra- 
tion and emaciation are such as to make it essential to procure some ali- 
ment that it will consent to take. We have, under such circumstances, 
given small portions of bread and butter, or stale sponge-cake, with weak 
brandy and water, if the child is old enough to swallow solid food. If the 
white of an egg be stirred in a small glass of water, the child will usually 
drink it freely without recognizing the presence of the albumen, and we 
are thus enabled to administer a considerable amount of nutritious food 
by giving the whites of two or three eggs in the course of the day. Some- 
times the child will eat small quantities of meat, and when this has been 
the case, we have not hesitated to allow a chicken-bone, with a little meat 
attached to it, or a piece of ham, or better still, a portion of roast beef, or 
of the tenderloin of beef-steak, to be held in the hand and sucked ; or we 
may give the white meat of chicken cut up very fine, or torn into the finest 
shreds. Of the latter about a teaspoonful is sufficient for the first day, 
given with a little brandy and water. The quantity can be gradually in- 
creased afterwards. We have of late years also given small quantities of 
raw beef in many cases, minced very fine and flavored with salt, or pre- 
pared in the manner described below,^ and have found it to be readily di- 

' The use of raw meat in the diarrhoea either of infants deprived of their mothers' 
milk, or of weaned children, was recommended by Weisse, of St. Petersburg, as 
loni; ago as 1840 (Oppenheim's Journal). Of late years it has been extensively 
used with excellent results, and is highly praised by Trousseau and other eminent 



I 



DIET IN THE CHRONIC FORM. 411 

gested and to agree well with the little patients. There is another article 
which we have sometimes given when children have been exhausted for 
want of food, and when they require constant change in order to be tempted 
to take it. This is the yelk of a /mr(/-boiled egg, which has the advantage 
of being very nutritious if digested, and of not being injurious should it 
happen to pass into the bowel in the crude state, as it falls into a state of 
fine powder, which is not irritating to that organ. 

The quantity as well as character of the food is of the utmost impor- 
tance, and should be strictly regulated by the physician, and attended to 
by the mother or nurse. As a general rule the child may be allowed as 
much as it wants of proper food, since the appetite is almost always greatly 
diminished, and it is not likely, therefore, that too much will be taken. 
If, however, there is disposition to nausea or vomiting, or if the appetite 
remain as good as usual, the quantity must be restricted. The difficulty 
in most ca.>es is to get the patient to take enough, and not to prevent it 
from taking too much, for we have very often ascertained, upon careful 
inquiry, that the quantity was entirely too small to support the strength of 
the constitution. A hearty child six months old, fed solely on artificial 
food, will generally take a quart of food in the twenty-four hours, while 
at a year old it will take usually fully a quart or three pints of fluid nour- 
ishment, besides eating small quantities of solid food. Now, we have fre- 
quently known children laboring under chronic entero-colitis, not to take 
more than one or two gills of food in the day, which is manifestly much 
too little. When this is the case, therefore, we should always endeavor to 
stimulate the appetite and digestion by means of tonics and stimulants, 
and by causing to be presented to the child such a variety of food as may 
entice it to take a larger quantity than before. 

authorities. The administration of the muscultir tissue itself appears much more 
useful than any form of beef essence or soup, probably for this reason among others, 
that these fluids pass too quickly through the intestinal canal. The best moat for 
the purpose is the fillet of beef, though fine mutton may also be used. It should 
be cut vcf}- fine, and according to Trousseau, poundod in a mortar and strained 
through a sieve or cullender ; the pulp, thus separated fr<^)m the cellular texture of 
the meat, may be rolled into small halls in .salt or powdered sugar. 

The quantity upon the first day should not exceed three drachms, given in di- 
vided doges; but it may be doubled on the successive days, until young children may 
take from six to ten ounces a day. Under this regimen the diarrhcea frequently 
ceases, and the children quickly recover their jtlumpness and natural spirits. 

Trousseau calls attention to the fact that the stools are frequently red and fetid at 
first, even when the nature and abundance of the diarrhoea have already undergone 
a favorable change. 

In a second article upon this subject (Jour, fiir Kinderkrankheiten, January and 
February, 1858;, Wei&.sc calls attention to the fact that in many children who had 
been treated by raw beef, tapeworms have been developed. As these worms were 
all specimens of taenia solium, which is not indigenous in St. Petersburg, it is prob- 
able, as suggested by Von Siebold, that they had been conveyed in the undeveloped 
state in the flesh of oxen, brought from distant points. We are not aware that this 
unfortunate consequence has been observed frer^uently in other localities, and cer- 
tainly in the quite numerous cases in which we have ourselves administered raw 
meat to children, no entozoa have been developed. 



412 ENTERO-COLITIS. 

In connection with this most important matter of the food, we will again 
quote from Dr. S. B. Hunt (ojo. cit., page 305), to sho^Y the results of his 
experience in the use of foods in chronic inflammatory diarrhoea in the 
army. For the sake of any non-professional reader, we will state that by 
albuminoid food Dr. Hunt refers to meat, meat-broths, eggs, etc. ; and by 
antiscorbutic food he means tomatoes, fresh fruits, onions, etc. Dr. Hunt 
says, " The value of drugs was, perhaps, overestimated in this, as in all 
other diseases of assimilation, and only a careful avoidance of the original 
causes of the malady, and an equally careful recognition of their continued 
existence in the system, could secure any degree of success. The scorbu- 
tic and malarial taints were almost uniformly present, the former very fre- 
quently in as pronounced a form as the latter. The bowels, enfeebled by 
the inflammatory process, were unable to perform their normal function of 
the digestion of starches, and the diet, therefore, became necessarily albu- 
minoid. A full nutritious diet of albuminoid and antiscorbutic food as- 
sumed the first importance in the treatment. Coupled with this came pure 
air and absolute cleanliness. And, with these hygienic measures alone, 
when they could be properly enforced, it was possible to treat chronic diar- 
rhoea and dysentery with a fair degree of success, even in the great heats 
of a Southern summer." These views confirm what we have said above, 
that milk, meat, raw or cooked, broths, eggs, gingerbread, tomatoes, bread 
and butter, and we may add currant-jelly, make the best food for children 
over two and three years of age. Even in children of eight months and 
a year or upwards of age, milk and beef or chicken tea ought to form the 
chief diet. The starches, such as arrowroot, barley, wheat preparations, 
etc., do not answer, except in very small quantities cooked in milk. We 
saw one child, a year old, weaned in August in consequence of the illness 
of the wet-nurse, whose life was apparently saved in dysentery by Liebig's 
cold extract of beef, and by its fortunately having developed a strong 
taste for the sucking of large pieces of rapidly and slightly cooked beef- 
steak. 

The therapeutical treatment of the chronic form consists principally in 
the administration of tonics, astringents, and absorbents. Of these the 
most important are the bismuth, powdered chalk and crab's-eyes, and the 
different vegetable astringents, which have already been noticed in the re- 
marks on the acute form. These are to be given in the manner there 
recommended, and it is therefore unnecessary to repeat what has already 
been said. In addition to these there are some remedies which are par- 
ticularly adapted to the chronic form of the disease. Amongst them is 
nitrate of silver. Dr. Eberle (op. cit., p. 251) says he has found its internal 
administration to produce the happiest effect in a few instances. His pre- 
scription was a grain of the nitrate dissolved in an ounce and a half of gum 
arable w^ater, with the addition of twenty drops of laudanum. The dose 
was a teaspoonful three times a day. He adds that he has never " known 
the slightest inconvenience to result from the use of this article in chronic 
mucous inflammation of the bowels, when administered in a mucilaginous 
solution and in very small doses." It has been much used of late years 
in France. MM. Trousseau and Pidoux recommend its internal use in 



TREATMENT OF THE CHRONIC FORM. 413 

the chronic diarrhoeas of children occurring during dentition, after bis- 
muth, powdered crab's-eyes, and diet have failed to effect a cure. Their 
formula is a^ follows : 

R. — Argent. Xitrat., ?•*. j. 

Aqu:v De.-tillat., ^o^'J- 

Syrup. Sarsjip., ....... l5ijss. — ^M. 

To be given in eight or ten doses. 

At the same time, they employ an enema composed of a grain of the ni- 
trate in three ounces of distilled water. It is highly recommended also in 
these eases by Hirsch, of Konigsberg. His formula is as follows : 

R. — Argent. Xitrrtt. Crystal., gr. J. 

Aqua? Destilliit., f.^ij. 

Aciici;e Pulv., . . . . . . • Bij- 

Sacch. Alb., ^ij — M 

A teaspoonful of this mixture to be given every two hours, and an enema, 
consisting of a quarter of a grain of the salt, with mucilage and a little 
opium, to be administered (Bankliig's Abst., No. vi, p. 61). We have em- 
ployed this remedy in the proportion of from half a grain to a grain in a 
gill of water, by injection, morning and evening, for several days, with 
very decided benefit, in three cases of diarrhoea following summer-com- 
plaint, in which the stools were frequent, mucous, sometimes streaked with 
blocKl, and accompanied by tenesmus. We have also given it frequently 
internally in mucilaginous solution, as above recommended, with excel- 
lent results. 

Dr. Woodward (op. cit., p. 264) says, in his article on the treatment of 
the chronic diarrha^a, which was a true entero-colitis, that "by far the 
most valuable local measure is the employment of solutions of the mineral 
a.«tringents as enemata." He mentions sulphate of copper, nitrate of sil- 
ver, sulphate of zinc, and acetate of lead, but thinks that the sulphate of 
copper and nitrate of silver are probably the most efficient. The strength 
he recommends is of one or two grains to the ounce of water, of which 
from one to six ounces may be thrown into the rectum two or three times 
a day. He advises that, when the rectum rejects the injection immedi- 
ately, twenty to forty drops of laudanum bo added to each enema, that the 
injection be thrown carefully into the bowel, and the nozzle of the syringe 
be withdrawn a.s gently as possible, in order that the fluid may be retained 
at least for some little time. We quote these statements, not to induce the 
use, in children, of solutions of one or two grains to the ounce, but to draw 
attention to one of the means, the ability and advantage of which bore the 
test of the vast army experience in this most severe and troublesome dis- 
ease. In children it is best to begin with a grain to four ounces, and, if 
this gives no pain, or but little, and does not produce the hoped for benefit, 
the proportion may be doubled, or, after two or three trials, brought up to 
that of a grain to an ounce. 

Another excellent remedy in the «hroiiic diarrlio-as of children, one 
from which we have sometimes obtained very satisfactory effects, is the 



414 ENTERO-COLITIS. 

syrup of the nitrate of iron. It is given in doses of from two to five drops 
three times a day, in sweetened water, at the age of one or two years. 

The following formula is recommended by Dr. Eustace Smith. We 
have used it ourselves in several chronic cases, and have been much pleased 
with its effects : 

R. — Liq. Ferri Pernitrat., .... fgss. 

Acid. l!s"itric. Dil., f^ss. 

Syrup. Zinzib., f^j. 

Aq. Anethae, ad f^iij. — M. 

A teaspoonful every six hours at one year of age. 

We have found a teaspoonful every three or four hours not too much at 
three and four years of age. 

Creasote also has been recommended of late years, and is highly thought 
of by some practitioners. It may be given in doses of from a quarter to 
half a drop every three or four hours at a year old. We have used this 
remedy in the following combination especially in cases attended with 
nausea, flatulent distension of the bowels, or a very fetid state of the dis- 
charges : 

R. — Creasoti, gtt. viij. 



I 



Sodae. Bicarb., . 
Sp. Lavandulae Comp., 
Pulv. Acaciae, Sacchari, aa, 
Aquae, .... 



gr. L. 

q. s. 

q. s. ad f§iij. — M. 



Dose, a teaspoonful three or four times a day. 

Bouchut recommends enemata of from ten to twelve grains of extract 
of rhatany, or six to ten of tannin, in about five to seven ounces of some 
vehicle. 

Sulphuric acid has been found very useful in the treatment of this affec- 
tion, and by some authors as, for instance, Pollak (Trans. Amer. Med. 
Assoc, vol. viii, p. 260) has been given in large doses as the sole remedy. 

We have never used it in this manner, but for some years past have 
been in the habit of employing it in the following mixture with excellent 
results. In cases of diarrhoea, showing a disposition towards dysentery, as 
often occurs in entero-colitis, and especially when the stomach has been 
irritable, so as to bear other medicinal substances badly, we have found 
this combination very beneficial. 

R. — Acid. Sulph Arora,, gtt. xlviij. 

Tinct. 0{)ii, gtt. xij, vel xxiv. 

Syrup. Krameriae, ..... f.f ss. 

Aq. Fluvial., fjijss. — M. 

A teaspoonful every two hours. 

It should never be forgotten in the treatment of chronic diarrhoea in 
children, that the most important point of all is the regulation of the diet 
and other hygienic conditions. We are fully convinced that we have seen 
several children saved from death by attention to these points, and by the 
persevering and careful employment of tonics and stimulants. It often 



TREATMENT OF THE CHRONIC FORM. 415 

happens, after the disease has lasted for some weeks or months, that the 
powers of the stomach are ahnost wholly lost. The child either refuses 
food or takes so little that the quantity is evidently insufficient to carry on 
the vital processes, or the greater part of what is taken is rejected by 
vomiting, or lastly, much of it passes off through the bowels, and appears 
in the stools in an undigested state, forming what is called lientery. If 
this condition of things is allowed to continue, the emaciation and exhaus- 
tion make rapid progress, and the case must soon terminate fatally. Under 
these circumstances all the ingenuity and skill of the physician are required 
to find articles of diet of a kind to recall and tempt the child's worn-out 
and often perverted appetite, and which, at the same time, may be digesti- 
ble and nutritious, and tend to restore vigor to the digestive function. If 
the stomach is frequently sick, it is best to abandon all remedies but those 
which are stimulating and strengthening, and especially to forbid all such 
as are in the smallest degree nauseous. We would indeed depend entirely 
on the use of repeated doses of the oldest and most delicate brandy that 
could be found, of which from one to two teaspoonfuls may be put into a 
wineglassful of cold water, and the whole given by teaspoonfuls in the 
twenty-four hours ; or fifteen to twenty drop doses of the elixir of Peruvian 
bark every three or four hours may be used ; or solution of pepsin, in half 
teaspoonful doses three times a day ; or, two or three drops of tincture of 
nux vomica in sweetened water three times a day, if the bitterness does 
not cause nausea or increase the loathing. In such cases, wine of iron, in 
doses of twenty drops to a fourth of a drachm, with syrup of tolu and 
caraway water, will sometimes do exceedingly well ; or the following, 
which has sometimes succeeded in our hands : 

R.— Tr. Ferri Chlorid., f^;]. 

Acid. Acet. Dil., f5J. 

Liq. Ammon. Acetat., .... f^ij. 

Syrup. Sirap., f^ss. 

Aquae, f^'j- — ^^^ 

Dose at four years, a teaspcK)nful, and under that age, half a teaspoonful, three 
or four times a day. 

In some very obstinate cases, especially where there is any reason to 
suspect the existence of a malarial element in the case, from half a minim 
to one minim of Fowler's solution of arsenic, with the wine of iron, three 
times a day, has been very serviceable. Whilst this is being done, an oc- 
ca.«ional dose of ano<lyne, ju.-^t enough to tranquillize without stupefNnng, 
may be given. If the rectum will retain it, it is better to give it by enema. 
In some cases we have found the aromatic .syrup of galls, given with brandy, 
to be taken by the child without any difficulty or disgust. 

Exerci.se by riding, and exposure to the air, which, however, must never 
be carried so far as to induce positive fatigue, are all-important. In .'<ome 
very severe and tedious cases, change of residence or travelling has been 
known to effect a cure after all remedies and other means had failed. In 
one case, in this city, which had lasted with but short intervals for two 
ytUB, we obtained a perfect cure by persuading the parents to send the 



416 CHOLERA INFANTUM. 

child into an elevated part of the country in the month of May, where it 
was kept until July, after which it was removed to the seaside until the 
end of August. Nothing was done in the meantime except to regulate the 
diet most carefully, and to keep the child the greater part of the day in 
the open air. 



ARTICLE III. 



CHOLERA INFANTUM. 



General Remarks. — In the early editions of this work we failed to 
draw with sufficient clearness the distinction between what we think ought 
exclusively to be called cholera infantum, and the much more common 
disorders which are properly styled simple and inflammatory diarrhoea or 
entero-colitis. In this we did but follow the practice of most American 
writers, and the custom of the day. Indeed, many physicians amongst us 
are still in the habit of designating the various intestinal disorders of chil- 
dren so frequent during the summer heats, under the common title of 
cholera infantum. We believe, on the other hand, that a large majority 
of the deaths registered in our mortality returns under this name, are the 
result not of a true choleraic disease, but rather of simple diarrhoea or 
entero-colitis. We have, however, only too often to contend with a dis- 
ease in children which deserves the title of cholera, which is the analogue 
of cholera morbus, or even of epidemic Asiatic cholera, in the adult, and 
which is the disease we propose to consider in the present chapter. 

Definition; Synonyms; Frequency. — We can define. cholera infan- 
tum only by an enumeration of its most specific characters, and we shall 
do this very much in the words in which Dr. Aitken describes epidemic 
cholera. Cholera infantum, as we understand it, is characterized by the 
occurrence, almost solely during the summer months, in young and gener- 
ally teething children, who have been previously either healthy or the sub- 
jects, for a longer or shorter time, of simple or inflammatory diarrhoea, of 
sudden muscular debility, occasional nausea, spasmodic griping pains in 
the bowels, depression of the functions of respiration, and an appearance 
of faintness ; copious purging of thin serous fluid, or of large watery and 
fetid evacuations, succeeded by more or less obstinate vomiting, coldness 
and dampness of a part or of the whole surface of the body, coldness and 
lividity of the lips and tongue, cold breath, a craving thirst, a feeble rapid 
pulse, difficult and oppressed respiration, with extreme restlessness, dimin- 
ished or suppressed urinary secretion, pallor of the entire surface of the 
body, a sunken and pinched countenance, weakness of the cry or partial 
aphonia, and collapse, more or less complete, which may prove fatal, or be 
followed by reaction, and a subsequent more or less severe and obstinate 
simple or inflammatory diarrhoea. 

This disease is not so common as simple and inflammatory diarrhoea, 



I 



CAUSES. 417 

most cases of which have been hitherto, as stated above, Improperly grouped 
under the comiiiou name of summer comphiint. Though rare in Europe, in 
comparison with its frequency in this country, it is easy to recognize from 
the descriptions, the identity of some of the cases called by Billard follicular 
enteritis, by Barrier apyretic and febrile follicular diacrisis, by Rilliet 
and Barthez, in their second edition, choleriform gastrointestinal catarrh, 
and by Copland, the choleric fever of infants, with the true cholera infan- 
tum of America. 

It is impossible to determine its real frequency amongst us, for the rea- 
son that fatal cases of simple diarrhea and entero-colitis, are so generally 
included in our mortality returns, with those of the true choleraic disease, 
under the common title of cholera infantum or summer complaint. That 
it is a frequent cause of death is shown, however, by the tables of Dr. 
Emerson {Am. Jour. Med. Sciences, vol. i, 1827), wherein it appears that 
from 1807 to 1827, 3576 deaths from cholera, under five years of age, were 
returned in this city ; of course many of these deaths were from a true 
choleraic disease. This is the largest number of deaths from any one dis- 
ease given in the table. The next largest item of mortality is under the 
head of convulsions, of which it appeal's that 3192 died in the same period 
of time. During the five years, from 1844 to 1848 inclusive, there occurred 
in this city, 18,599 deaths from all causes, under fifteen years of age. Of 
this total, 1611 died of the so-called cholera infantum, which is the largest 
number of deaths from any one disease, with the exception of convulsions. 
Of convulsions there died 1729. After cholera infantum the largest num- 
ber of deaths was caused by marasmus (1060 \ dropsy of the brain (1041), 
pneumonia (772), and croup (756). Cholera infantum, therefore, in these 
tables, causes nearly as many deaths as convulsions during the first fifteen 
years of life, and rather more than twice as many as pneumonia. We also 
refer the reader to the table given at pages 382-383, obtained from the 
Board of Health of this city, exhibiting the mortality under five years of 
age from cholera infantum, diarrhoea, and dysentery, with the total mor- 
tality at all ages, and with the mean temperature of each month. 

Causrs. — In discussing the causes of cholera in children, we meet again 
the difficulty so often alluded to, viz., the custom in this country of class- 
ing in mortality returns, all the deaths from intestinal aflTectious in child- 
ho<xJ, under the common title of cholera infantum or summer com])laint. 
Our own exj^erience leads us to the conviction that the causes are the same 
a.s those of simple and inflammatory diarrhoea, acting with greater inten- 
sity. When that cause, or those causes, whatever they may be, act with 
moderate frjrce, the result will probably be a simple or inflammatory 
diarrhoea. When, on the contrary, the causes are intensified in degree, 
the case will be apt to take the form of choleraic disorder. Thus hcdt is 
one of the most influential of these causes. So long as the atmospheric 
temperature is moderate, the resulting disorders will probably tjike the 
form of simple or inflammatory diarrhrea. But let the temperature rise 
to 85** or 95° Fahr., or even higher, as happens occasionally in our sum- 
mers, and continue at that height for three or four days, and children 
previously well will be seized with the true choleraic forms of diarrhoja, 

27 



418 CHOLERA INFANTUM. 

whilst those who are already suffering with simple or inflammatory diar- 
rhoea, are prone to have these milder diseases assume suddenly the 
choleraic type. 

A glance at the table above referred to, shows most plainly the effect of 
heat upon the mortality from bowel diseases in children, under five years 
of age. It will there be seen that, in the two months of July and August, 
when the mean monthly temperature is between 75° and 80°, the mortality 
from cholera infantum rises to between two and four hundred, and even 
over ; whilst during the cool months, as January, February, November, 
and December, when the mean monthly temperature is between 30° and 
40° generally, only one, two, three, or none at all, are reported. This 
table shows also, what we have so frequently remarked upon, that most of 
the fatal cases of bowel disease, in early life, are classed in the medical 
returns of this city, under the common title of cholera infantum, whereas, 
we are sure from our own personal experience, that many of these deaths 
would be more correctly referred to simple or inflammatory diarrhoea, or 
entero-colitis. Thus, in the very months when three and four hundred 
deaths are grouped under the title of cholera infantum, only from fifteen 
to twenty, or a little over, appear usually under the term diarrhoea. 

Diet. — Improper diet is another frequent cause of choleraic disease in 
hot weather. Sudden weaning, a change in the character of the artificial 
food, the unfortunate use by accident, or by the carelessness of the nurse, 
of unwholesome milk, of improper vegetables, or, as not unfrequently 
happens, of green or unripe or unhealthy fruit, as apples, currants, goose- 
berries, or blackberries (instances of all of which we have ourselves met 
with), will sometimes bring on, in a very few hours, the most violent at- 
tacks of cholera, or convert a previously mild and comparatively safe 
diarrhoea into the more violent form of disease we are considering. These 
results are especially apt to follow such accidents or imprudences in large 
cities, where the hygienic conditions are always in summer of a kind to 
invite the more violent and dangerous forms of intestinal disorder. In 
fine, the conditions which have been ascertained to be most certain to 
produce epidemic cholera, when that disease is present in a locality, are 
those which develop cholera in children. To put before the reader the 
conditions most certain to cause cholera in children, we cannot do better 
than to quote from the Report on Epidemic Cholera to the Citizens' Asso- 
ciation of New York, in 1865, the localizing causes of cholera. 

These are : 

1. Decaying organic matters, bone, hide, fat and oflfal houses, neglected 
stables, putrescent mud and filth. 

2. Bad drainage, local dampness, malaria. 

3. Obstructed sewers, filthy streets, gutters, stables, garbage, and cess- 
pools. 

4. Water and beverages in any manner contaminated by putrescent 
organic matter, particularly by any soakage from privies. 

5. Neglected privies and putrefying excrement. 

6. Overcrowding and neglect of ventilation. 

It is just where these conditions are most rife that choleraic diseases in 



CAUSES. 419 

children are most apt to occur. Amongst the poor, who inhabit the 
crowded quarters of cities, where the streets and alleys are small and nar- 
row, where heaps of decaying vegetable and organic matters abound, where 
water is scant or scantily used, where ventilation, from the manner in 
which the streets are laid out, and from the crowding together of buijdings, 
is necessarily imperfect, we have the most numerous and the severest forms 
of the disease. Add to these the small size of the houses, the low ceilings, 
the small and few windows, and the interior arrangement of the rooms, 
which is such that a thorough draught is unattainable, and we need not 
wonder at the prevalence of the disease. It is amongst the poor, too, 
that the food is often of necessity, as well as from ignorance and reckless- 
Dess, of the most improper kind, and not unfrequently insufficient in 
quantity. 

But not only the poor, in their unhappy lot, suffer from this disease. 
The children of the rich, with all the advantages of the most wholesome 
hygienic appurtenances which ease and knowledge can supply, are apt to 
contract it if they remain in town during the hot summer months. So 
well is this known, that most families in easy circumstances leave the city 
for the seaside or the interior, so long as their children are young, remain- 
ing absent usually from the middle of June to the middle or end of Sep- 
tember. It is nevertheless true that, whilst all the residents in our cities 
during the summer season are liable to see their young children suffer 
tVom this disease, tliose who are so fortunate as to occupy large and airy 
houses in the best and cleanest quarters, and who follow a wise system of 
hygiene as to diet, water, dress, and exposure to fresh air, escape with 
much more certainty the disease than those who are compelled by the 
necessities of their position to submit to the unhealthy conditions men- 
tioned above. 

Dentition. — We believe this also to be a most powerful predisposing 
cause of the disease, and yet it would seem to be less influential than age, 
for the tables of Dr. Emerson show that it is about twice as fatal in the 
first year as in the second, though the process of dentition is certainly 
more active and continuous in the second than in the first year. We have 
rarely observed it before the beginning of the process of dentition, and it 
is certainly very rare after its completion. 

Age, as has just been stated, exerts a strong influence in the production 
of the diseaije. In the tables of Dr. Emerson, the ca-ses of cholera in- 
fantum and cholera morbus are included under the one head of cholera, 
but an all cases of the disease under five years of age are called cholera in- 
fantum, the want of the distinction does not make the statements less use- 
ful to us. From them it appears that there were 2122 deaths in the first 
year, 1186 in the second, and only 268 between the second and fifth. Be- 
tween five and ten years, only 52 cases are noted, and these would of 
course be entitled cholera morbus. In the five years, from 1844 to 1848 
inclusive, of 1611 deaths from cholera infantum under 15 years of age, 
969 occurred in the first year of life, 529 in the second, 103 between two 
and five years, and only 10 after that age. 

Sex. — There are no large tables of reference, by which to ascertain the 



420 CHOLERA INFANTUM. 

exact proportion in which the disease occurs in the opposite sexes. It 
would appear, however, from our own experience, to be much more com- 
mon in males than females, since of 77 cases of which we have kept a 
record, 48 occurred in boys, and only 29 in girls. 

Constitution. — The disease is most apt to occur in feeble, delicate chil- 
dren, and in those of nervous, irritable temperament. 

Hereditary Predisposition. — Our own observation leads us to believe 
that the disease is apt to occur in certain families. It would seem prob- 
able that this peculiarity must depend on the fact that the constitutions of 
some families are particularly disposed to disorders of the digestive appa- 
ratus. AVe are acquainted with one family in this city, in which eight out 
often children, suffered more or less from the disease. Again, of these 
children four have grown up, married, and have children. Two of these 
families have each lost a child from the disease; in a third, the tw^o chil- 
dren of the family have been exceedingly ill with it; while in the fourth, 
some of the children have been sick, though not to the same degree. 
Again, we have attended two children in a family, one not quite two years, 
and the other three months and a half old, who have both been very sick 
with the disease. The elder child was ill the summer before in the same 
way. The mother of these children was herself very ill with the disease 
on several occasions during her infancy, as was also her brother. 

Anatomical Lesions and Pathology. — It will be readily under- 
stood that it is far from an easy task to define precisely what are the essen- 
tial lesions in true cholera infantum, as we have described it. Having 
been confounded so long with ordinary inflammatory diarrhoea, the lesions 
usually attributed to it are precisely those we have detailed in our article 
on the latter affection. In those cases again where the true choleraic dis- 
ease appears during the course of inflammatory diarrhoea, it is of course 
difficult to determine to which affection the lesions presented after death 
are in reality due. We must, therefore, seek for the true and proper 
lesions of cholera infantum in the comparatively rare cases in which this 
affection has appeared in the midst of good health, and has proved fatal 
during the acute stage. With this restriction then, it appears that the 
only anatomical changes which can be regarded as constant and essential 
to the disease, are enlargement of the mucous follicles, and, to a less de- 
gree, of the glands of Peyer ; and softening, and in some cases erythema- 
tous inflammation of the mucous membrane. 

There can be little doubt that the appearances thus indicated, depend 
upon the presence of an early stage of inflammation of the tissues of the 
intestinal walls, and of the mucous follicles. This view is supported by 
the similarity between these lesions and those found in cases of entero- 
colitis, proving fatal during the early stage, as well as by the fact that 
where the child survives the choleraic stage, and ultimately dies after a 
continuance of diarrhoea for some days, or even several weeks, the lesions 
are found to have developed into those ordinarily found in primary entero- 
colitis. 

It is, however, necessary to consider briefly what additional element is 
present, in this form of disease, which impresses upon it such peculiar and 



ANATOMICAL LESIONS AND PATHOLOGY. 421 

fatal features; or, in other words, what is the pathology of the collapse 
which characterizes cholera iutautiim. 

It is a matter of much regret, that as yet we are wantiug in careful 
microscopical examinations of the condition of the epithelium of the mu- 
cous membrane, and of the characters of the evacuations. We should 
anticipate, however, from the evident similarity between cholera infantum 
;ind sporadic cholera, or cholera morbus in the adult, that in the former 
as in the latter disease, such examination would reveal rapid proliferation 
and exfoliation of the cells of the mucous membrane. 

In regard to the explanation of these lesions, we would refer the reader 
to the remarks upon the pathology of entero-colitis, where we have ex- 
pressed our belief that the causes of these affections (heat, noxious emana- 
tions, unwholesome food), act in a complicated manner, by inducing a state 
of malnutrition in which the tissues are prone to undergo inflammatory 
changes, by loading the blood with noxious substances, which may irritate 
the glands which excrete them, and finally by interfering with digestion, 
so that the contents of the intestinal canal undergo changes which render 
them highly irritating. 

We repeat that we recognize in cholera infantum the presence of the 
general alteration of nutrition, and the change in the entire blood-mass, 
as well as the local irritant action of the morbid contents of the intestines. 
But it is in the highest degree interesting and significant of the impor- 
tance of this last element in the causation, that symptoms altogether indis- 
tinguishable from those of cholera collapse, may be produced by agencies 
acting directly and solely upon the coats of the stomach and intestines. 

Attention has been lately directed to these analogous conditions by Sedg- 
wick, in a highly valuable article, " On some Analogies of Cholera, in which 
suppression of uriiie is not accompanied by symptoms of urcemic poisoning " 
(Med.-CJiir. Trans., vol. li, p. 1, 1868), in which he has collected many 
such examples. Among the causes which are clearly established as capable 
of producing such an analogous condition, are poisonous doses of corrosive 
-ublimate, arsenic, some of the mineral acids, especially nitric acid ; and 
ilso of certain drastic purgatives, especially crotou oil. In these cases the 
•••culiar symptoms produced, which are uniformly described by accurate 
Ijservers as most closely analogous to those of cholera collapse, are due 
exclusively to the direct irritant action of the substance upon the gastro- 
intestinal mucous membrane. 

The same effects have frefjueutly been observed to follow the eating or 
drinking of poisonous animal matters, such as tainted or simply unwhole- 
some meat or fish, and milk which has undergone some injurious, but as 
yet unknown change, decomposing vegetables, and some of the poisonous 
fungi. In this last group of ca-ses, the local irritant action of the substances 
swallowed, must certainly be regarded as the principal cause in the pro- 
iuction of the symptoms, although it is quite possible that the ingestion of 
such putrid animal or vegetable substances should also cause an altered 
condition of the blood. 

In like manner, there are numerous morbid conditions of the intestines, 
or their peritoneal covering (as perforation with subsequent peritonitis, 



422 CHOLERA INFANTUM. 

peritonitis from extension of inflammation, intestinal obstruction), which 
may be attended with symptoms closely analogous to those of cholera 
collapse. 

We will also quote from Rilliet and Barthez, the following passage in 
regard to the remarkable memoirs upon Inanition, by Dr. Chossat, of 
Geneva, which show the analogy which exists between the results of experi- 
mental inanition and the chief symptoms of cholera infantum. "This is 
seen especially (1.) In the diminution of temperature, which conjoined with 
the loss of weight, is in inanition, as in cholera infantum, one of the prin- 
cipal causes of death. (2.) In the stupor which follows the jactitation as 
the temperature falls. (3.) In the colliquative diarrhoea during the last 
few days of life, the severity of which is proportioned to the rapidity of 
the fatal termination, and to the increase of the algidity." 

It is not within the scope of the present work to discuss, critically, the 
various theories which have been advanced to explain the modus operandi 
of such causes in producing a state of collapse analogous to that of cholera, 
as well as the pathology of true cholera collapse. 

It is, however, evident, that the mere drain of fluid from the alimentary 
canal, although it undoubtedly has much influence upon the course of the 
disease, cannot be regarded as the efficient cause of collapse, since in many 
cases profound collapse occurs with comparatively scanty discharges. 

So too we must regard Dr. Johnson's hypothesis {Medico- Chir. Trans., 
vol. li, 1867, p. 103, et seq.), that the symptoms of collapse are due to a 
spasm of the minute branches of the pulmonary artery, caused by the spe- 
cific alteration of the blood in cholera, as based upon insufficient argu- 
ments. Thus, in the first place, we have cited instances above where symp- 
toms altogether similar to those of cholera collapse, are produced under 
circumstances in which it is impossible even to suspect the existence of a 
poisoned state of the blood. Again, there is neither any clinical nor ana- 
tomical evidence to show that the contraction of the pulmonary artery is 
relatively greater than that of the rest of the arterial system ; or again, 
that such contraction precedes the other signs of collapse. 

In an earlier edition of this work, we quoted the opinion of Rilliet and 
Barthez in regard to the implication of the sympathetic nervous system in 
cholera infantum, and since that time we have been led to regard this more 
and more strongly as the essential cause of the collapse which character- 
izes this and other choleraic conditions. 

The passage extracted from the admirable work of Rilliet and Barthez 
was as follows : " The disease we have just described is, in our opinion, a 
catarrh which has localized itself upon the digestive tube and the great 
sympathetic nerve. It is, of all forms of the catarrhal affection, that which 
most clearly justifies the idea of a poisoning. It proves also that anatom- 
ical differences alone will not suffice to establish a separation between the 
various species of the disease. 

" Its catarrhal nature is demonstrated by the causes, which are those of 
all catarrhs (improper alimentation, epidemic influence, etc.) ; by the anal- 
ogy of the symptoms ; by the gradual passage of the mild into the grave 



ANATOMICAL LESIONS AND PATHOLOGY. 423 

forms, through intermediate cases ; and lastly, by the fact that simple in- 
testinal catarrh is often but the prodrome of choleriform enteritis. 

*' Reasoning from the simple fact that the disease is catarrhal, we admit 
the existence of a moditication of the whole economy, and of some alter- 
ation of the blood. 

"A study of the anatomico-pathological descriptions of the disease, and 
especially the observation of cases, demonstrates that the gastro-intestinal 
tube of children dying of this affection may be found in four different con- 
ditions : 

"a. Either the stomach is softened without any lesion of the digestive 
tube. 

" b. Or the stomach is softened, at the same time that the mucous mem- 
brane of the intestines, and especially its follicular apparatus, is diseased. 

"c. Or the stomach is healthy, whilst the follicular apparatus or the 
mucous membrane are diseased. 

" d. Or, lastly, the gastro-intestinal tube fails to exhibit any lesions ap- 
preciable by our senses in the present state of our knowledge, or it presents 
alterations too insignificant to explain the gravity of the symptoms." 

. . . . " Up to this point the disease resembles all other catarrhs, but what 
gives to it a special type is the abundance of the serous secretions and the 
disturbance of the great sympathetic nerve. 

"The serous secretion, which seems to be produced by perspiration (analo- 
gous to that of the respiratory passages and of the skin), rather than by a 
follicular secretion, shows, perhaps, that the elimination of morbid matter 
is accomplished by other organs than the follicles ; and we ought perhaps, 
to see in this a proof that the matters to be eliminated are not the same as 
in simple catarrh. On all these points we are compelled to remain in doubt ; 
we content ourselves with stating the fact. 

"The functional derangements of the trisplauchic nerve play an im- 
portant part in the disease ; under this point of view it differs from the 
mild form, in which the innervation is normal, and from the cerebral 
form, in which it is especially the cerebro-spinal apparatus that is sym- 
pathetically affected. The proof of a disturbance of the ganglionic ner- 
vous system, rests upon the following physiological and nosological consid- 
erations : 

** The dis*ease exists at the age and in the physiological condition (denti- 
tion ), in which functional derangements of the nervous system without 
lesions of organs are most frequent; it is often complicated with those 
very disorders of the general innervation, as is proved by certain profound 
changes in the functions of nutrition, circulation, and calorification, which 
the amount of material waste will not always account for. We occasion- 
ally obser\-e the same symptoms of nervous sideration, and particularly the 
extreme smallness of the pulse, and the algid phenomena, to arise in certain 
of the most violent attacks of spontaneous peritonitis. Now these phenom- 
ena, which cannot always be referred to the intensity of the pain, and which 
do not exist in inflammations of the other serous membranes, no matter 
what the rapidity of their course, are only to be explained by the fact that 



424 CHOLERA INFANTUM. 

the disease, seated in the abdomen, envelops the ganglia of the great sym- 
pathetic nerve." 

Since the date at which this was written, our knowledge of the functions 
of the sympathetic nerve, especially with regard to its power of regulating 
the calibre of the arteries, by inducing contraction or allowing relaxation 
of their muscular coat, has been much advanced ; and we are fully pre- 
pared to understand how the symptoms of cholera collapse might be 
explained upon the supposition of a widespread powerful irritation of the 
fibres of the sympathetic nerve, so richly distributed to the coats of the 
vessels throughout the alimentary canal, and which have such intimate 
relations with the nervous supply of the whole arterial system, as well as 
of the heart and lungs. 

Thus we can most readily explain in this way, the small, thready 
pulse ; the cold, pale, and shrunken skin ; the asphyxia and coldness of 
the breath ; the diminution in the formation of urea and in the secretion 
of urine. 

The above views of the pathology of choleraic collapse, have been of late 
ably supported by Sedgwick {loc. cit), and Dr. Horace Jeaffreson (^Edin. 
Med. Jour., December, 1866, p. 520). 

At the same time, the probability is that the vaso-motor nerves of the 
intestinal walls themselves are paralyzed, from exhaustion of their excita- 
bility, so that dilatation of the vessels occurs with profuse discharge of 
serum. 

So far as experimental research can be made available in deciding 
questions involving such deepseated and delicate parts, the results en- 
tirely confirm the explanation given above. Thus Moreau^ has found 
that, after section of the branches of the sympathetic nerve supplying the 
intestines, a copious secretion of alkaline serous fluid takes place into the 
bowel. 

Symptoms. — Restricting, as we now do, the term cholera infantum to 
cases which have a truly choleraic character, we shall have a smaller 
ground to go over than we had in our early editions. 

The invasion of the choleraic symptoms is sudden. The child may have 
been quite well previously, or may have been the subject for an indefinite 
length of time — days or weeks — of simple or inflammatory diarrhoea, 
when, from exposure to high summer heats (85° to 95° Fahr.) in a city, 
or more rarely, in the country ; from being allowed to take some unwhole- 
some article of food; from the effort of cutting teeth; or perhaps from 
having been chilled by night-air, or by a sudden change of the weather 
from hot to cool ; the choleraic disorder breaks out, with almost simulta- 
neous vomiting and purging. The diarrhoea is, from the beginning, vio- 
lent. The stools are usually frequent, consisting almost entirely of a thin 
fluid, which runs through the napkins and wets the clothes of the child. 
Sometimes the discharges are not very frequent, but each one may be so 
large as to wet not only the napkins and clothes of the child, but to run 

1 Comp. Kend. de I'Acad. des Sciences, t. Ixvi, p. 554, 1868, in Medical Times 
and Guz., April 11th, 1868, p. 397. 



SYMPTOMS. 425 

through to the hip or bed on which the patient lies. Tlie chief and im- 
portant characters of the stools in true cholera infantum, as in cholera of 
the adult, are their fluidity and quantity. These two characters, more 
than the vomiting or the nature of the discharges in any other respect, are 
the special signs of the disease, and by the degree in which they are pres- 
ent do we recognize the disease, and usually determine its severity. The 
fluid thus rendered by stool may be of different characters. It may be an 
almost colorless liquid, merely wetting the napkins and clothing, as though 
they had been dipped into a bucket of water, or saturated with the pale 
urine of a healthy infant: or they may consist of the same watery fluid, 
holding in suspension small and soft flocculi of fecal matter of a yellowish 
or greenish color, or small detached portions of mucus, which are left upon 
the napkins as the watery fluid drains through them. When the stools are 
of this kind, they are usually almost inodorous. In other cases, they are 
still very watery, but the fluid is yellowish or brownish in color, contains 
rather a larger amount of thin feculent matter, and has a most offensive 
odor, — an odor which is peculiar for its extreme fetidity, a fetidity so great 
that we have known it to cause vomiting in those exposed to it, and so ad- 
hesive as to render it necessary to change at once all the clothing and 
bed-linen of the child, and even then the fetor may cling to the body of 
the patient, after repeated washings. This odor we have seldom met with 
except in the choleraic form of summer diarrhoea. The number of the 
stools varies greatly. We have known as many as twelve to be passed in 
as many hours. In other cases they are not so frequent, but the quantity 
at each time may be so great as to drain the body of its fluids at a more 
rapid rate than many more evacuations of an ordinary size. Eight, twelve, 
fifteen, or more than twenty stools in twenty-four hours are not rare. In 
one fatal case, in a child between one and two years old, there were be- 
tween twenty-five and thirty stools during the second night of the attack, 
in a space of twelve hours. 

Simultaneously with, or soon after the diarrhoea sets in, there is vomit- 
ing. The matters vomited consist at first of the ordinary contents of the 
stomach, food, and water. Soon these matters consist of the water or 
medicines that may be taken, and of a serous or sero-mucous fluid mixed 
with small portions of bilious matter. Sometimes they are tinted green as 
80 often happens in the gastro-intestinal aflfectioua of children. The vom- 
iting may or may not be very frequent. Sometimes it is one of the se- 
verest elements of the disease, causing everything taken to be rejected 
almost as s^>on as swallowed, or assuming the form of repeated and ex- 
hausting retching, even when the stomach is quite empty. In connection 
with these symptoms there is rapid loss of strength. The child is listless 
and still between the evacuations and vomiting, or tosses and moans with 
the jactitation of severe illness. The api>etite is lost, but thirst is extreme, 
and constitutes one of the marked phenomena of the disease. Water and 
ice are seized upon with the greatest avidity, and taken almost incessantly, 
if allowed, though rejected only a few moments afterwards. 

The abdomen is flaccid or retracted, not tender to the touch usually, 
and the walls inelastic, so that they can be readily pinched up into folds. 



426 CHOLERA INFANTUM. 

The tongue, moist at first, with a thin white fur upon it, becomes pasty or 
dryish after a time, and is sometimes protruded from time to time between 
the lips. 

The pulse runs up from the first, rising soon to 130, 140, and 150, and 
being usually small in volume, whilst the temperature remains for a time 
normal, rises slightly above the natural point, or, in some few cases, the 
skin becomes hot. The urine diminishes in all these cases, and in very se- 
vere ones, ceases to flow, or flows only in the smallest quantities. As in 
true cholera, the degree of suppression of this function is in proportion to 
the severity of the choleraic discharges. The respiration, natural at first, 
soon becomes, if the case goes on unfavorably, irregular, unequal, and anx- 
ious. The temper is irritable at the beginning, the child being restless, 
peevish, disposed to fret and cry at the least contradiction or disturbance. 
The sleep is restless and disturbed, especially at night. The child wakes 
frequently, and almost always with crying. When asleep, the eyes are 
often but half closed, and the brow contracted and frowning. The coun- 
tenance soon becomes anxious and distressed. In sudden and severe at- 
tacks, it is languid and subdued, pale and contracted. 

If the disease is not soon checked, signs of collapse make their appear- 
ance, and become more and more marked features. The body becomes 
cool and then cold, the pulse grows smaller, thready, and very rapid ; the 
features are drawn ; the nose is sharp and thin ; the eyes shrink within the 
orbits ; the cheeks become sunken ; the patient passes into a still, quiet, 
and drowsy state ; the vomiting may cease, but the diarrhoea usually per- 
sists ; the child falls into a comatose or semi-comatose state, and death 
occurs quietly in this condition, or may be preceded by slight convulsive 
movements. According to the researches of Koger {op. cit, p. 399), the 
reduction in the temperature of the axilla never approaches, in these cases 
of sporadic cholera, that which is found in cases of the true epidemic form 
occurring in children. Some very violent cases run their course in a day, 
a day and a half, or two or three days. We, ourselves, do not recollect to 
have seen any case terminate sooner than in three days and a half. 

In favorable cases, after one, two, or three days, the diarrhoea ceases to 
be so violent ; the stools grow less frequent, smaller in quantity, thicker 
in consistence, containing a better-concocted fecal matter, and regaining a 
more natural odor. The vomiting and thirst gradually subside ; food is 
again taken and retained; the circulation falls, and the child, though weak 
and thin, and the subject for some days of a simple diarrhoea, may regain 
its health in great measure, at the end of a week or ten days. More fre- 
quently, however, the disease assumes the form of a more obstinate simple, 
or inflammatory diarrhoea, which may last for several weeks, to take on 
again, perhaps, from a recurrence of the exciting causes, the choleraic 
form, or to persist in one of the former shapes until the return of cool 
weather. 

Such is a picture of the disorder to which we think the name of cholera 
infantum ought to be restricted. If physicians could agree to limit the 
title to this true choleraic disease, our mortality returns would soon show 
the comparative frequency of death from this disorder, and from those 



DIAGNOSIS — PROGNOSIS. 427 

more tedious and chrouic diseases which have already been treated of under 
the designation of simple and inflammatory diarrha\a or entero-colitis. 

The duration of cholera infantum, as we restrict the term, is seldom more 
than two, three, or four days. It may prove fatal in a much shorter time. 
Dr. Eherle (Dis. of Children, p. 285) says it sometimes runs on to a fatal 
termination in live or six hours. Dr. J. Lewis Smith i^o]). cit., p. 392) re- 
ports a case in a child sixteen months old, which ended fatally in less 
than one day; a second, at seven months, after a sickness of about one 
day ; and a third, at twenty months, in thirty-six hours. We do not recol- 
lect, in our own experience, which has been chiefly in private practice, a 
shorter case than one of three days and a half. In favorable cases the 
diarrhoea usually pei*sists, as already stated, for several days after the dis- 
appearance of the choleraic phenomena, and very frequently runs on into 
a simple or inflammatory diarrhoea, which follows the law of these dis- 
orders. 

Diagnosis. — The diagnosis of cholera infantum requires no particular 
elucidation. The season at which it is most prevalent; the profuse, serous, 
or at least fluid evacuations; the frequent and severe vomiting; the early 
exhaustion of muscular strength ; the rapid pulse, with absence of, or a 
very moderate febrile heat; the threatening or the actual supervention of 
collapse, marked by cool or cold surface, pinched and anxious countenance, 
shrivelled skin, sighing or irregular respiration, rapid and feeble or ex- 
tinguished pulse, diminished or suppressed urinary secretion ; with, finally, 
the still and limp body, and drowsy or comatose brain, all mark a disorder 
which is readily recognized after being once seen, or which may be dis- 
tinguished by any intelligent person who has never yet met with such a 
case, if only the progression of the symptoms be carefully inquired into, 
and correlated with the present condition. 

Pro<;nosis. — Cholera infantum, as we restrict the use of the term, is, of 
course, always a dangerous disease. Collapse, which either threatens all 
who are attacked by it, or actually supervenes to a greater or less degree, 
is well known by all physicians to be one of the most formidable morbid 
conditions to which the body is liable. The degree of danger in any indi- 
vidual case must dej^end chiefly upon the ability of the physician to arrest, 
and of the patient to resist, this state. The probability of the supervention 
of collapse depends very much upon the hygienic condition in which the 
child is placed, upon the age of the patient, the stage of the process of 
dentition, the pre?*ent state of health, the innate vigor of the (;onstitutional 
force, and also, we may say, upon the period of the disease and the degree 
of wisdom with which medical means are applied. Children placed in 
favorable hygienic conditions in the country, or in the healthier parts of 
cities, in large and well-ventilated rooms, and who have been fed upon 
proper diet, and who have therefore been attacked by the disease whilst in 
previous fair health, are much more apt to escape collapse, or to recover from 
it after it has made its appearance in a more or less marked degree, than 
those who are placed in conditions the opposite of those we have enumer- 
ated. Early age, recent weaning, im[)n»f)cr artificial diet, and feeble vital 
powers from any cause, either inherent or acquired, are amongst the most 



428 CHOLERA INFANTUM. 

unfavorable prognostics. Still, we should never despair until the last mo- 
ment, since we have seen some most surprising recoveries from apparently 
desperate conditions in this disease. 

The prognosis may be stated in general terms to be unfavorable in pro- 
portion to the frequency and violence of the vomiting, the number of the 
stools, the severity of the fever, and the more or less marked character of 
the collapse. When the discharges consist merely of serous fluid, and are 
copious and frequent ; when they consist of small quantities of deep-green 
matter, mixed with much mucus or with blood ; when accompanied by 
straining; when they number from fifteen to twenty-five in the day; when 
they are very fetid ; and when, with these symptoms, the abdomen is 
tense and tympanitic, the countenance pinched, the expression languid, the 
extremities cool, the pulse rapid and small, and the child irritable and rest- 
less, or, on the other hand, very still and subdued, the prognosis is exceed- 
ingly bad. If, after the symptoms just enumerated, drowsiness or stupor, 
and then coma, convulsions, rigidity, or paralysis make their appearance, 
there is scarcely a hope left. 

The favorable symptoms in any case are, diminution of the fever; equal 
temperature of the whole surface ; cessation of vomiting ; decrease in the 
number of the stools, and a return to their natural color, consistence and 
odor ; quiet, tranquil sleep ; return of appetite ; and lastly, a restoration of 
the natural temper and gayety of the child. 

Prophylactic Treatment. — The danger to which teething children 
are exposed from residence in this city during the hot months of the year, 
is now so well understood that most families who can aflfbrd it remove to 
the country during the warm season, and by this course very generally 
avoid the disease. It is undoubtedly the best plan that can be adopted, 
and very commonly succeeds. When this cannot be done, however, the 
prophylactic treatment consists in a most careful attention to diet, dress, 
and exposure to the open air. If possible, the child should be kept at the 
breast until it has passed through its second summer, as there is but little 
danger from the disease after that period. If the weaning must take place 
prior to that age, it ought to be accomplished before the hot weather begins, 
as a change from the breast to artificial food during the warm season is 
very apt to bring on the disease. If the child is weaned, the diet must be 
strictly attended to. Up to the age of ten months or a year, the food 
should consist almost wholly of milk containing arrowroot, rice, oatmeal, 
or some farinaceous substance in small quantity. A little plain chicken 
or mutton water, with rice boiled in it, or a piece of beef or chicken to 
suck, may be given occasionally, but all vegetables and fruits should be 
strictly forbidden. After the age of ten months, some light soup and small 
portions of mutton, chicken, or very tender beef, minced very fine, may be 
given every day in addition to the milk food, which must still form the 
major part of the child's nutriment. Fruit of all kinds, all vegetables ex- 
cept rice and potatoes, and the latter are doubtful, ought to be carefully 
avoided until after the hot season has passed entirely away, or until the 
child has its full set of teeth. We have found the food prepared with 



\ 



TREATMENT. 429 

gelatiu, in the manner described, to answer better than anything else for 
a large number of children to wliom we have prescribed it. 

The dress onght to be arranged according to the heat of the day. We 
have not rarely known young children to be kept clothed all summer in 
this city in thick flannel jackets, and petticoats, and woollen >ocks. This 
is certainly too much for the hot days which so frequently occur in July, 
August, and early in September, and is often, we believe, very injurious. 
A light gauze flannel shirt is the only woollen garment that need be worn 
during the warm season. On hot days a child should have only this, a 
muslin petticoat and frock, and the lightest possible socks, or none at all. 
If, as constantly happens in our climate, a cool day comes, there should be 
added to these a light flannel petticoat. 

It is of the utmost importance that children should pass as large a por- 
tion of the day as possible in the open air. In the country this is easily 
managed, and parents almost always contrive to accomplish it; but in a 
city, many people seem to think it of less importance, or their servants 
are occupied with other things, and it is neglected. It is nevertheless a 
matter of the greatest consequence ; the child ought to be kept in the air 
by the nurse for several hours in the morning and evening, either in the 
garden attached to the house, if there be one, at the front door, walking 
in shady streets or public squares, or, better still, making short excursions 
into the neighboring country, taking care, however, to avoid the intense 
heat of the sun during the middle of the day. 

We believe that with constant and wise attention to these points, viz., 
diet, dress, exposure to the air, and exercise, much may be done towards 
preventing the disease even in families obliged to remain in the city dur- 
ing the summer. 

As stated in the account of the symptoms, the choleraic disease often 
supervenes in children who have already been the subjects of simple or in- 
flammatory diarrhoea. When, therefore, a child in the city has diarrhcea, 
if it do not yield readily to treatment, and especially if the stools begin 
to be thin and watery, with any marked tendency to exhaustion, it ought 
to be regarded as being threatened with cholera. In such an event, the 
best prophylaxis in the world is instant removal to some high country 
locality or the seaside. 

Treatment of the Attack. — Regarding this disease as a truly chol- 
eraic one, we shall follow, in the consideration of its treatment, the plan 
adopted by some of the more recent writers on Asiatic cholera ; and shall 
accordingly divide our discus.sion of this sul)ject into the treatment appro- 
priate for the three stages of evacuation^ eollapue, and reaction. 

Every young child who is attacked with diarrhoea, whether simple or 
inflammatory, in the sumn)er season, ought to be regarded as liable to 
cholera, and should be carefully watched to prevent the development of 
this disease. For the propf*r treatment of such conditions, the reader is 
referred to the article on those aflections. 

Should a child, either previously well, or the subject of diarrha?a of the 
ordinary form, be attacked with sudden, jjrofuse, frequent, and watery dis- 
charges, and especially, should these be associated with vomiting, with 



430 CHOLERA INFANTUM. 

spasmodic intestinal pain, and with any appearance of general exhaustion, 
it ought to be presumed to be in the early or evacuation stage of cholera 
infantum, or in what is the analogue of the evacuation stage of epidemic 
cholera. Under these circumstances, it has been a prevalent practice here 
to give a cathartic, castor oil, calomel, or rhubarb. We think the prac- 
tice wrong, unless there be positive evidence that the attack has followed 
directly upon the use of some unwholesome article of diet. If it be found 
that the child has certainly eaten some such food, green apples, currants, 
gooseberries, or articles of this kind, and that these have not come away 
in the discharges, it is right to give first a moderate purgative. We pre- 
fer castor oil or syrup of rhubarb, half a teaspoonful of the former, or a 
teaspoonful of the latter, with two drops of laudanum at the age of one 
year, or a teaspoonful of castor oil, or two of the syrup of rhubarb, with 
four drops of laudanum, or two drops of chlorodyne,^ at two or three years 
of age. Two hours after this dose, if the stools continue frequent and 
watery, we use the chalk mixture, with tincture of krameria and lauda- 
num or paregoric (a teaspoonful of the chalk mixture with ten to fifteen 
drops of the krameria, and one drop of laudanum, or five of paregoric) 
every two hours at the age of one year. Thirty drops of the syrup of nut- 
galls (see article on entero-colitis), with an opiate every two hours, is often 
very useful. We believe that the great object is to arrest the watery dis- 
charges by stool. If the above means fail, laudanum may be given by in- 
jection, and two drops at one year, and double the dose at two years, every 
two or three hours, may be tried in addition to the above treatment. The 
quantity of opium must depend on its effects. Children, like adults, bear 
very different amounts. As soon as positive drowsiness appears, or the 
pupils become contracted much below their natural size, the doses must be 
suspended or diminished, or the intervals between them lengthened. Of 
course, if the stools lessen in frequency, quantity, or fluidity, the same 
reduction in the amount of the opium ought to be made. 

When vomiting is severe and frequent, and the above remedies are re- 
jected, we may use the one proposed in the article on inflammatory diar- 
rhoea, consisting of solution of morphia, dilute sulphuric acid, and curacoa 
cordial. This, or some similar remedy, is at times very successful. It is 
nineteen years since one of us saw a child nine months old, in deep col- 
lapse from a most violent attack of cholera infantum, who rejected its 
mother's milk as though it had been tartar emetic, whose stomach was 
only made worse by calomel, but who began to improve very soon upon 
doses consisting of two drops of aromatic sulphuric acid, and five drops of 
solution of morphia, in a teaspoonful of iced water, every hour. Since 
then we have frequently used the mixture above recommended in such 
cases, and we think, on the whole, with more control over the vomiting 
than anything else we have tried. 

' The preparation which we prescribe under the name of chlorodyne is not Dr. 
J, Collis Browne's, but is made by Messrs. Bullock & Crenshaw of this city. It 
contains one grain of morphia to the fluid drachm ; but, as it does not drop less 
than 120 to the fluid drachm, the dose for an adult is 10 to 15 drops. It is a very 
elegant preparation, and has proved most efficient in our hands. 



i 



TREATMENT. 431 

The experience gained by careful and lengthened observation in the 
treatment of the evacuation stage of Asiatic cholera, may well be applied 
to the affection under consideration, so much alike are they. Dr. Good- 
eve {Inc. cit., p. 177) gives fii*st a full dose of opium (he says that calomel 
was genei-ally combined with it in India, and though he does not " know 
that the calomel does good, it does no harm"), to an adult two grains, 
and half an hour afterwards he begins with an astringent, in his own prac- 
tice, usually the following mixture : 

R. — Plumbi Acetat., . . • gr. xxx. 
Acid. Acet., .... ti^x, 
Aq. Destillat., . . . . f^vj.— M. et ft. sol. 
One ounce or half an ounce every half hour or hour. 

At the end of an hour from the administration of the first dose of opium, 
if the purging persisted, he gave one grain of opium and continued the as- 
tringent. A small teas})oonful, or two-thirds of an ordinary teaspoonful of 
this solution would contain about half a grain of the acetate of lead, and 
this might safely be given to a child a year old for several doses. We have 
not used this remedy ourselves, but it comes from a source which commends 
it^lf to us, and we shall not hesitate to use it when the occasion presents 
itself. As soon as the frequency of the discharges is arrested, the doses 
should be given at longer intervals, and when the peculiar serous character 
of the stools has disappeared, this remedy ought to be suspended, and some 
more simple one substituted, in order to avoid the possibility of producing 
the toxic action of lead. 

If, in spite of the treatment, the stage of collapse should set in, other 
methods of treatment must be adopted. Here the stools are usually in 
great measure arrested, or they are few in number and small in amount. 
The object to be sought after is to produce reaction, or rather to favor the 
efforts of nature to bring about this change. It is now generally acknowl- 
edged by men of large experience, that the old plan of pouring in large 
doses of opium and alcohol is a great mistake. But little is absorbed by 
the stomach whilst the body is in this condition, and not unfrequently the 
patient is injured, perhaps fatally, by the sudden absorption of these sub- 
stances, when the stomach begins to act after reaction has taken place. 
The opium may cause dangerous or fatal stupor, or may increase or keep 
up the tendency to suspension of the urinary function, and thus ])r()mote 
one of the great dangers of the disease, uraimic intoxication. The alcohol, 
if it ha.s been u.sed in large quantities, would also tend to clog the nervous 
centres, to cause gastric or gastrointestinal catarrh, and to heighten beyond 
a safe point the febrile movement which is so apt to accompany the reaction 
stage. Opium, therefore, should be avoided during collapse, or given only 
in the smallest doses. Alcohol, though it should never be given in large 
doses, and reckles.sly, as has so often been done, may be used in small 
quantities, especially if it be found by close watching, that it promotes the 
force and volume of the pulse. Ten or fifteen drop doses of old and deli- 
cate brandy, in a teaspoonful or tablespoonful of ice-water, may be given 



432 CHOLERA INFANTUM. 

every hour or two hours, at oue year of age. During collapse the stomach 
is still often very irritable, and yet the thirst continues intense. We are 
glad to find that such men as Drs. Maclean and Goodeve recommend the 
free use of ice and water under these circumstances. Our own practice, 
for years past, has been to allow ice and cold water, almost without limit, 
to children in this condition, and we are much pleased to know that such, 
too, is the practice of these gentlemen. We never could understand the 
wisdom of refusing water to patients who were suffering the horrid thirst 
produced by the immense losses of the water of the body by serous purg- 
ing. The degree of thirst for water (a natural and not a secondary dis- 
eased instinct, like that of the drunkard for alcohol) must be the safest 
guide we can have as to the need of the body for water, and as such, it 
ought always, it seems to us, to be gratified, unless under very rare and 
most peculiar conditions. We give water and ice, even though the child 
vomits from time to time, believing and hoping that some will be absorbed 
to take the place in the tissues of that which has been drained off through 
the intestines. This point in the treatment we regard as so important, and 
one, we think, so much misunderstood by the public and by some medical 
men, that we make the following quotation from a note of Professor Ma- 
clean's to Dr. Aitken {Aitken's Practice, vol. i, footnote, page 663) : 
" Urgent thirst is one of the most distressing symptoms in cholera ; there 
is incessant craving for cold water, doubtless instinctive, to correct the in- 
spissated condition of the blood, due to the so rapid escape of the liquor 
sanguinis. It was formerly the practice to withhold water — a practice as 
cruel as it is mischievous. Water in abundance, pure and cold, should be 
given to the patient, and he should be encouraged to drink it, even should 
a large portion of it be rejected by the stomach ; and when the purging 
has ceased, some may with advantage be thrown into the bowel from time 
to time." The use of water by enema, when the diarrhoea is checked, is 
a point which ought not to be neglected, especially if the stomach con- 
tinues weak and irritable. A gill of tepid water may be used at a time, 
thrown slowly and gently into the bowel, in the case of a child one or two 
years old. If this is retained well, the same quantity may be repeated in 
one or two hours. 

Whilst the collapse lasts, but little food can be taken. It is seldom re- 
tained if used in any quantity, and the stomach has lost, in great measure, 
its digestive power. The only food we have found at all available has been 
thin chicken tea, Liebig's cold extract of beef, or weak wine-whey, given 
in two or three teaspoonful doses, every half hour or hour. It is worse 
than useless to attempt more than this, as not only is it not retained, but 
it evidently tends to keep up the nausea and vomiting, and thus retard the 
natural effort at reaction. As to remedies in this condition, we doubt 
whether anything better can be done than to use water, as just advised, 
and small doses of brandy, and, if they can be borne, small quantities of 
the liquor ammonise acetatis, ten to twenty drops, in cold water, every hour, 
at one year of age. There is, however, a remedy which has obtained a 
great reputation amongst the English army surgeons in India, for the pro- 
motion of reaction in the collapse stage of epidemic cholera, which we 



TREATMENT. 433 

have used ourselves with advantage in adults, but uot in children, though 
we propose trying it when we next have a good opportunity. It is spoken 
highly of by Dr. Maclean. The formula is as follows : 

H— 01. Anisi, 01. Cajeput., 01. Juniper., aa, . . f^ss. 

^EihtT., f^ss. 

Liq. Acid. Hallori, f5^s. 

Tinct. Cinnumom., ...... f^ij. — M. 

The dose for an adult is ten drops every quarter of an hour, in a tablespoonful of 
water. 

An opiate may be given with the first and second doses, but should uot 
be con tinned, .for the reasons already given. The liq. acid. Halleri consists 
of one part of concentrated sulphuric acid to three parts of rectified spirit. 
The dose of this mixture for a child a year old, ought, we think, to be about 
one or two drops in a teaspoonful of water, given, as above stated, every 
quarter of an hour. So much is this valued in India, according to Dr. 
Maclean, that it is always ordered to be kept in store in the " medical field 
companion " of armies on the march. 

It must not be supposed that all children seized with choleraic diarrhoea 
are necessarily to pass through the collapse stage in all its terrors. On 
the contrary, many, when judiciously treated early in the disorder, escape 
collapse altogether, and yet they have had none the less the true choleraic 
disease. Others suft'er more profuse and exhausting losses of water by the 
discharges, or their vital power of resisting disease is less, and they pass 
into more or less deep collapse ; or hang, as we have seen them, on the 
very edge of that condition, for one or two days, and then emerge from 
the danger, without having done more than cause the experienced physi- 
cian the grave anxiety which such suspense must and ought to create. 
During these doubtful moments of the attack, the child should be kept as 
quiet and still as possible. He should be made to lie in a constantly hori- 
zontal position, on a smooth and easy mattress, in the crib, or on a large 
and roomy bed, and as little as may be on the lap, which is uneven and 
unsteady, and which must give his weak and exhausted muscles more work 
to do than they would have on the more solid and even bed. If, however, 
the nature of the child be such that he clings to the mother's or nurse's 
lap as his only safety, or if he have been taught (a most ill-judged lesson) 
to prefer the lap to any other position, we must yield to him, rather than 
cau.se fretting or unhappiness, when his very life may hang upon the avoid- 
ance of all disturbing influences. In this case, it is well to ])lace him upon 
ae firm a pillow as can be found, and let him be held on this in the lap. 
It is imjwrtant to move him, when this becomes neces.«»ary, as slowly and 
gently as possible, always keeping the body on a horizontal plane, to avoid 
the tendency to the syncopal state, which sudden movements, and efspeci- 
ally the sitting or erect position, are apt to produce. When the tendency 
to cooling of the body shows it.«elf, and this is usually first noticeable in 
the hands and feet, ears and nose, he should be kept wrapped in warm, 
dry, and soft flannels or blankets. Flannels heated at the fire, thus sup- 

28 



434 CHOLERA INFANTUM. 

plying dry artificial heat, are of great use here. Bottles or tins filled with 
hot water, ought to be placed at the feet, under the blanket. A warm, 
soft, and light poultice of Indian meal or flaxseed, with a little mustard 
incorporated with it, may be placed over the abdomen, or three or four 
thicknesses of flannel, wrung out of hot water and whisky, may be laid 
over the lowest part of the thorax and over the abdomen, and covered with 
oiled silk, to retain their heat and prevent the wetting of the clothes. 
Whilst artificial heat is thus made use of, fresh air must not be excluded. 
On the contrary, as these cases almost always occur in the hottest summer 
weather, the largest supply of fresh air that can be obtained must be ad- 
mitted. Warm baths, which were proper and useful during the early stage, 
especially when fever was present, we have not found useful in these cases. 
The fatigue and irritation caused by the disturbance of undressing and 
dressing the child, have seemed to us to do more harm than any good de- 
rived from the heat of the water compensated for. 

When the case takes a favorable turn, and the reaction stage begins, it is 
usually best to do nothing more than supply food and water carefully, and 
keep the body quiet and tranquil. The food may be cautiously and slowly 
increased in quantity, if the stomach has become settled. Tablespoonfuls 
of thin chicken tea, just flavored with salt, or of Liebig's cold extract of 
beef, or of light beef tea, or of a mixture of wine-whey with two or three 
parts of thin arrowroot decoction (a teaspoonful to a pint), may be given 
every half hour or hour. If these are retained several times, and the child 
shows some little anxiety for food, the same materials may be given in 
wineglassful quantities. At the same time, water and ice ought to be al- 
Jowed from time to time, as the thirst may call for them. On the second 
•or third day of the reaction, we may give, if the child shows a desire for 
it, a little milk and water and lime-water, one part of milk to one or two 
of water, with one of lime-water, commencing with not more than two or 
three ounces of the mixture at each feeding. The milk ought certainly to 
'be very much diluted for the first three or four days after it is allowed. 
When the child has been carried thus far safely, we may gradually return 
.to its former habits of feeding, allowing meat to suck, a little bread, and 
•so on, if it is old enough for such habits. 

As to drugs during the reaction stage, they are not necessary if every- 
thing goes on well. If, however, the fever run high, we may use small 
doses of the spirit of nitrous ether, as ten drops, in iced water, every two 
hours at one year, or twenty drops of the solution of acetate of ammonia, 
in the same manner, at the same age. If, as often happens, the urinary 
secretion remains scanty, water, in such quantities as the stomach takes 
willingly, amkes probably the best diuretic ; or we may use the spirit of 
nitrous ether, as just recommended, with a grain of acetate of potash and 
half a drop to a drop of tincture of digitalis, every two hours, for a day or 
two. 

When reaction is thus successfully brought about, the child may either 
improve rapidly and regain its previous health, or simple or inflammatory 
diarrhoea may set in, and pursue the usual course of those disorders. In 
the latter event, the child, if the attack of cholera have occurred in the 



TREATMENT. 435 

city, ought certainly to be removed to the country if possible, since it is 
only too apt to have a recurrence of the choleraic disease if kept in town, 
or to suHer, at least, a tedious and more or less dangerous attack of the 
simpler form of diarrhcea. For the proper treatment of either of these se- 
quences to cholera, the reader is referred to the articles on those diseases, 
with the warninir, however, that all such patients ought to be treated with 
every minute care as to hygienic and therapeutic measures that experience 
and art have taught us, since the health has been so rudely shaken by the 
sickness already endured. 

We have now laid before the reader, to the best of our ability, what we 
think is the best method of treating cholera in children ; but, before quit- 
ting the subject entirely, we wish to make a few remarks upon points not 
referred to in the above account. 

Attention to the state of the gums should never be neglected in teething 
children. Our experience leads us to believe most implicitly that the pro- 
cess of dentition, or at least that and other concomitant constitutional con- 
ditions, are constant predisposing causes of gastro-intestinal disorders in 
early life, and that the active hyperaemic state, or positive acute inflam- 
matory condition, which often attends upon the near approach of teeth to 
the surface of the gum, may become an exciting cause of acute digestive 
diseases, such as cholera. We think it is always well, therefore, to exam- 
ine into the state of the month in a choleraic child as in other infantile 
disorders; and if the teeth are felt distinctly through the gums, and the 
gums be found swollen, tense, hot, and highly vascular, to cut them freely 
once. If, on the contrary, the gums are firm, not hot, not redder than 
usual, and the edges of the teeth cannot be felt, it is foolish meddlesome- 
ness to cut them. 

Baths. — In the early stage of cholera, before collapse has begun, and 
whilst the child is still reasonably strong, and particularly when there is 
marked febrile heat and dryness of the body, we think that the use of the 
warm or hot bath, or of sponging with hot water and spirit, are excellent 
measures. The bath may be used twice, or even three times a day if the 
child does not resist and scream. The temperature should be 95° to 98°, 
and the child may be kept in the water from five to ten minutes. It is 
an excellent plan to wrap the child, directly on lifting it from the bath, 
in a heated muslin sheet, and to apply over this a blanket, and keep it 
thus enveloped on the lap for half an hour or more if it is comfortable 
and disposed to rest. If the child be somewhat weak, whisky, added to 
the water, renders the bath more useful and safe. When the use of a bath 
alarms or annoys so as to cause violent agitation, it is best to substitute 
sponging with hot water and whisky or vinegar, under a light blanket, 
two or three times a day. 

Aniiphlogisiics. — It may appear to many, in these modem times, a mere 
waste of words for us to state that we are opposed to bloodletting, in any 
form or at any stage of cholera infantum. But if any such will take the 
trouble to look over the works of writers of ten and twenty years back, 
he will find reason to think that if this be our opinion, it ought to be ex- 
pressed. When one of ourselves began to practice, in 1841, it was quite 



436 DYSENTERY. 

the custom to take blood for the nervous symptoms which are present in 
the early stage, and still more for the comatose phenomena at the close. 
This was done on the theory that these symptoms were the result of con- 
gestion or inflammation of the brain, whereas now they are looked upon 
as the results of exhaustion, of the altered conditions of the blood, or of 
ursemia. 

Calomel. — The opinion was expressed in a former edition of this work, 
that the doses of calomel usually recommended were too large for young 
children, and were apt to aggravate the existing irritation of the digestive 
mucous membrane ; and that such doses of a remedy acknowledged to be 
a powerful sedative, could not be proper in a disease which constantly 
tended towards exhaustion and collapse. It was also stated that the small 
doses which we did recommend had been declared by some critics to be 
entirely too small,, and that to this we could only reply that the larger 
and more careful, and, we hoped, the wiser our observation had been in 
the last few years, the more thoroughly convinced were we that the larger 
doses, such as were formerly recommended and used by nearly all writers 
and practitioners, were not only unnecessarily large, but most seriously 
objectionable. We went on to say that the indiscriminate use of this 
remedy, in nearly all cases of the gastro-intestinal diseases of childhood 
became with some, we believed, a mere routine habit — that they never 
tried what might be accomplished without it, but went on pushing the 
drug in constant doses, when the case, if trusted to simpler means, or even 
left to the efforts of nature, would often do much better, we had learned 
to believe, than when these delicate organs were made the receptacle of 
doses that could not but tend to keep up the nausea, and vomiting, and 
diarrhoea, which form so important a part of the morbid phenomena. The 
experience w^e have had since that time has but confirmed us in these 
opinions. Indeed we have so often been disappointed in obtaining any 
good effects from this drug, and have so often had reason to think that, 
instead of allaying nausea and vomiting, it increased them, and added to 
the exhaustion which is one of the dangers always to be contended against, 
that we have virtually abandoned its use in this affection. 



ARTICLE IV. 



DYSENTERY. 



It seems to us unnecessary to make more than a few remarks on dysen- 
tery, since we have already spoken of the morbid conditions of the large 
intestine, in our article on entero-colitis. Dysentery, however, differs from 
this latter affection by the fact that it frequently occurs in an epidemic 
form, and that there is a tendency to more rapid and extensive ulceration 
of the mucous membrane of the rectum and colon. It is an acute febrile 



CAUSES — ANATOMICAL LESIONS — SYMPTOMS. 437 

disease, characterized by frequent evacuations, attended with more or less 
severe pain and straining, and consisting of muco-sanguinolent or sangui- 
neous substances, which are due to ulcerative inflammation of the rectum 
and colon. 

The causes of dysentery are but little understood, beyond the mere facts 
that it occurs as an endemic in some regions of country, and as an epi- 
demic over large districts. It is frequent, also, as a sporadic disease, and 
in this form seems to depend upon the same causes as those already cited 
as productive of entero-colitis. Like cholera infantum, it appears to be 
more common in boys than girls, since of 39 cases of which we have kept 
notes, in which the sex is mentioned, 27 occurred in boys, and only 12 in 
girls. It is most frequent in the second and third years of life. Of 38 
cases in which the age was noted, 1 occurred in the first year of life, 15 in 
the second, 7 in the third, 3 in the fourth, 3 in the fifth, 1 in the sixth, 3 
in the seventh, 3 in the eighth, and only 2 from the eighth to the end of 
the eleventh year. It may be either idiopathic or secondary. As a sec- 
ondary aflection it is most apt to follow measles and variola. We have 
often known dysenteric stools to occur in the course of cholera infantum, 
and in a considerable number of cases such as we have described under 
the title of entero-colitis. 

The anatomical lesions are confined chiefly to the large intestine, and are 
the same as those described under the head of entero-colitis, except that 
they are of a graver character. The mucous membrane is commonly found 
thickened, swelled, red, and softened ; the submucous tissue sometimes pre- 
sents ecchyraosed points ; the follicles are often diseased, their orifices being 
enlarged and ulcerated, as described under entero-colitis. In grave cases, 
particularly those occurring under an epidemic influence, there are usually 
more or less extensive ulcerations, which may implicate only the mucous, 
or extend to the muscular or even the peritoneal coat. In such instances, 
pseudo-membranous exudations are often formed, sometimes in large quan- 
tity, and often covering the ulcerations. The intestine contains sanguino- 
lent mucus, or at times a brownish or greenish material which is evidently 
the result of a gangrenous condition of the mucous membrane, pus, and 
lastly false membranes. In some rare cases, perforation has been known 
to take place. 

Symptoms. — The symptoms are much the same as those already described 
as existing in entero-colitis, excepting that the local symptoms are more 
severe, and the presence of blood in the stools constant. The disease often 
begins as a diarrhfra. The stoola at first contain feculent materials, but 
after a time become very thin, small in quantity, and consist chiefly of 
mucus mixed with blood. The blood may be black and in considerable 
quantity, or of a dark rosy red color, or like the washings of flesh ; it is 
mixed with greenish or yellowish substances, whitish mucus, fragments of 
false membrane, or purulent fluid. In young children there is evidently 
pain^ from the restlessness, moving of the limbs, and crying about the time 
of the evacuations, while in those who are older, there is true fotesmim, like 
that observed in adults, and severe pain in the anus. The number of stools 
varies according to the severity of the case. There may be only four, eight, 



438 DYSENTERY. 

or teu in the day, or many more. We have quite frequently known as 
many as 30 and 40 to be voided in the twenty-four hours, and in fatal cases, 
the dejections sometimes number three or four in an hour, while between 
the discharges the child often suffers from most violent and painful tenes- 
mus. 

The abdomen is generally distended, tympanitic, warmer than natural, 
and painful. 

In mild cases there- is usually no fever, or very little, while in severe at- 
tacks, there is high fever during the first few days, marked by frequent 
pulse, hot dry skin, followed after a time, unless a favorable change takes 
place, by coolness of the surface, contraction of the countenance, hollow, 
sunken expression of the eye, rapid emaciation, and death. 

It is useless to give a longer detail of the symptoms, as they are the same 
as those already described in the article on entero-colitis. 

The diagnosh presents no difficulties. The frequency of the discharges, 
the pain in the course of the colon and in the anus^ the tenesmus, the char- 
acter of the evacuations, and the febrile reaction, all make the disease easy 
of recognition. 

The prognosis is favorable in mild eases, unattended with much fever, 
or very frequent discharges. When^ on the contrary, there is violent fever 
in the beginning, followed by disposition to coolness and collapse ; when 
the stools are exceedingly frequent, and attended with severe pain and 
almost constant straining ; and when they consist of nothing but mucus, 
mixed with considerable quantities of blood, or with pus or false mem- 
branes, the prognosis is very unfavorable. Of 36 cases, the termination of 
which we have recorded, 4 proved fatal. 

Treatment. — The treatment of dysentery in children is often very un- 
satisfactory. The mere variety of the remedies recommended by difierent 
writers and practitioners marks the uncertainty of the effects obtained from 
drugs. Mild cases so generally get well under any treatment that all 
methods have had their supporters and advocates, while grave cases, and 
especially those occurring under the influence of severe epidemic visitations, 
are so difficult of treatment, and often so little under the evident control 
of medical means, as to leave the careful observer in great doubt as to what 
he ought to set down as the evident result of his own interference in the 
case, and what as the results of the efforts of nature to cure the disease. 

Mild cases of the disease, in which the fever is not very high, the num- 
ber of stools not great, and the pain and distress moderate, require little 
else than rest in bed, a light and unirritating diet, and the use of opium in 
small quantities either internally or by injection. When there is reason 
to suspect the presence of unwholesome food in the stomach, or of unhealthy 
secretions in the intestines, it is necessary to give in the beginning small 
doses of some mild cathartic. The one generally preferred is castor oil, 
which may be given either simple, in the dose of a small teaspoon ful con- 
taining one to four«drops of laudanum according to the age, or in the form 
of emulsion. The latter is the mode of employing it usually chosen. A 
drachm of oil should be rubbed up with a scruple of gum, a little sugar, 
from two to eight drops of laudanum, according to the age of the child, 



TREATMENT. 439 

and seven drachms of some aromatic water. The dose is a teaspoonful 
every three or four houi-s. If the case continue to improve under the 
emulsion, it may be continued for a couple of days, but should the stools 
become more and more frequent, and the pain and tenesmus increase, it 
must be suspended after one or two days, and laudanum enemata, with or 
"without the internal use of absorbents and astringents, substituted. The 
injections ought to consist of four or five drops of laudanum at two years 
of age, and of ten drops at five or six years, suspended in from half an 
ounce to an ounce of some mucilage, or thin fiirinaceous fluid, or simply 
mixed in a tablespoonful of tepid water, which is perhaps the best plan of 
all. The injections may be given every four or six hours if necessary, or 
they may be made use of only at night, while small doses of Dover's pow- 
der are administered every three or four hours through the day. 

The diet in these cases should consist of arrowroot, sago, tapioca, or 
some such food, made into thin pap with milk and water ; and the quan- 
tity allowed ought to be very moderate. Rest in bed, in the cradle, or in 
the lap, is very important. The child ought not to be allowed to run 
about, or use exertion of any kind. 

Where the pain is severe and the fever high, and where there is a good 
deal of soreness in the abdomen, depletion may with propriety be resorted 
to, but always with moderation and prudence. A few leeches applied 
around the margin of the anus, or to the surface of the abdomen, often 
prove of great service in relieving pain and tenesmus. An occasional 
warm bath is very soothing and useful. 

In very severe cases of dysentery the treatment is, as above stated, diffi- 
cult and uncertain, owing to the dangerous character of the disease, and 
to the fact that so many different methods have been recommended by dif- 
ferent writers. 

In the early stagp of a severe case, whilst the febrile reaction is high and 
the strength of the patient still unsubdued, depletion by leeches in young 
children and by venesection in older ones, is strongly approved of by many 
able practitioners. For our own part we have not resorted to it as a gen- 
eral rule, from the fact that we have so often found the strength of the 
child to fail rapidly under the disease itself. In a few of our cases, how- 
ever, leeching around the anus has been followed by manifest benefit. The 
remedies most commonly depended upon are castor oil in emulsion with 
laudanum, mercury, sugar of lead, opium, nitrate of silver, spirit of tur- 
pentine, and astringents. The castor-oil emulsion, prepared as mentioned 
above, is useful in the early part of the attack, but ceases to be so, ac- 
cording to our experience, after the first twenty-four or forty-eight hours. 
From mercurj' we have not ourselves obtained any very positive benefit, 
though, in combination with opium and ipecacuanha in small doses, it is 
much tnought of by many excellent authorities. The only remedy which 
is used by all, though it is rarely given alone, is opium, and the very fact 
that it is so univer^ally employed jK)int3 it out as one of the most reliable 
and valuable means we have at our command. It is certainly the one 
upon which we most depend ourselves. It may be given either alone or 
in connection with other substances. Where rnjections can be retained it 



440 



DYSENTERY. 



is best given in that way. About five drops of laudanum at two years of 
age, or ten drops at four or five years, may be given in a tablespoouful 
of any bland vehicle every four hours. When the rectum rejects the 
enema as soon as administered, the opium should be given either by the 
mouth, in the form of laudanum or solution of morphia, or in that of 
Dover's powder ; or in the form of suppository. We should indeed strongly 
recommend the administration of opium in this latter form in such cases, 
since we unquestionably obtain a certain beneficial local action, in addition 
to its constitutional effect through its absorption. The amount of opium 
should be about the one-eighth of a grain at two years of age, which, together 
with any other remedy, such as acetate of lead, if it be desired, should be 
incorporated with butter of cocoa, a most bland and soothing substance, 
which dissolves readily at the temperature of the body. When made of 
this substance, and of proper shape and sufficiently small, the suppository 
can be introduced without pain, and will usually be retained. They should 
of course be repeated at intervals, depending upon the effect produced. 
Opium is almost always employed in connection with some other remedy, 
and particularly with calomel or acetate of lead. The dose of calomel is 
from a sixth to half a grain, or, as used by some practitioners, a grain with 
a twelfth of a grain of opium, or half a grain or a grain of Dover's powder, 
every three or four hours, for children two or three years of age. The 
acetate of lead is more relied upon, and has probably higher testimony in 
its favor than calomel. We have ourselves obtained excellent effects from 
it in some instances. The dose is from half a grain to a grain every two 
or three hours at two and three years of age. 

There are two other remedies not yet mentioned, which have been of more 
positive efficacy in our own practice than any others, with the exception of 
opium. These are the nitrate of silver and the solution of the nitrate of 
iron. The former we have used both internally and by injection, the latter 
only by injection. For an account of the mode in which these remedies 
are employed by different authorities, the reader is referred to the remarks 
on chronic entero-colitis. We have employed nitrate of silver in 14 cases 
of dysentery. These were all severe attacks, and some of them most violent. 
Of the 14 cases, three died. The remedy was given by the mouth alone in 
7 cases, by injection alone in 5, and by the mouth and by injection both in 
2. It has proved most beneficial in its effects, in our hands, when given by 
the mouth, though its influence over the disease has always been less im- 
mediate than when used by injection, but it has been more permanent. 
The dose in which we have used it has varied with the age of the child, 
and with the severity of the symptoms. For children two years old we 
have usually employed from one grain to one and a half grains, and for 
those of five or six years or upwards, two grains dissolved in two ounces 
of a vehicle, consisting of an ounce each of syrup of gum arable and dis- 
tilled water. The dose is a teaspoonful every two or three hours. It is 
well, as a general rule, to add from four to sixteen drops of laudanum, ac- 
cording to the age of the subject, to the mixture. For use by injection we 
have commonly employed for each enema two grains for young children, 
and four grains for older oties, dissolved in four ounces of distilled water. 



DISEASES OF THE CCECUM AND APPENDIX CCECI. 441 

The injections are to be repeated twice or throe times a day. After the 
nitrate of silver enema has come away, it is a good plan to throw into the 
bowel a laudanum and starch injection. 

We have made use of the solution of nitrate of iron, to which allusion 
was made above, only as an injection in acute dysentery. We have em- 
ployed it in eight cases, and are quite sure that it was of essential service 
in six, while in two it appeared to irritate, probably because the quantity 
given was too large. Our mode of applying it is to mix from ten to twelve 
drops in four ounces of tepid water for each injection. The injections 
were given twice or three times a day, and they were followed, as soon as 
they hatl returned, by a laudanum injection. On two occasions, the nitrate 
of iron injection remained in the bowel for several hours before being re- 
jected, and thus restrained for that time the stools, which had previously 
been very freciuent, and attended with much tenesmus. 

When the stools continue very frequent in spite of the use of opium in 
8ome of its many shapes, when sugar of lead and nitrate of silver have 
been employed without controlling the frequency of the discharges, we 
have sometimes found the mixture of aromatic sulphuric acid, laudanum, 
and syrup of rhatany, before recommended, very beneficial. When the 
stools, in addition to their dysenteric characters, have been watery, and 
greenish in color, the chalk mixture, with laudanum and tincture of rhat- 
any, kino, or catechu, repeated every two hours, with occasional laudanum 
enemata, has been very useful. 

The hygienic management of dysentery should be precisely the same as 
that which was suggested as proper for entero-colitis. 



ARTICLE V. 

DISEASES OF THE (XECUM AND APPENDIX CCECI — TYPHLITIS AND 
PERITYPHLITIS. 

Synonyms; Definition. — The diseases of the cnecura and of its ver- 
miform appendix are so important and frequent, and present so many 
peculiarities, as to demand a separate and detailed consideration. In ap- 
proaching their discussion, it is neces>ary to bear in mind several important 
pf>ints in which the ccecum differs from the rest of the large intestine. 
Thus its peritoneal investment is deficient over the posterior part, which is 
generally quite firmly attached to the right iliac fossa by connective tissue, 
containing a small profKjrtion of fat. Its anatomical relations moreover 
indicate that the .'K?mi-feculent materials passing from the ileum are des- 
tined to be retained in the ccecum to undergo some important action. The 
ileum at its lower portion rarely has a calibre greater than one-third that 
of the co'cum, a circumstance which must materially retard the progress 
of the couteuts of the latter, and a further detention is caused by the 



442 DISEASES OF THE COiCUM AND APPENDIX CCECI. 

ileo-ea?cal valve, which prevents all reflux, aud by the position of the 
coeeum, which compels it to force onwards its contents in opposition to 
gravity. The view that the coeeum is the seat of an important part of the 
digestive process, either in the appropriation of any remaining nutritious 
elements of the semi-feculent chyme, the absorption of its watery parts, or 
the elimination of some excrementitious matter from the system, receives 
confirmation from the very rich vascular and glandular supply of the 
walls of this part of the intestine. 

In addition to this, the coeeum has opening into it, usually at its lower 
and back part, the appendix vermiformis, a narrow, elongated, glandular 
process, varying from three to six inches in length, and having an average 
diameter about equal to that of a goose-quill, although its calibre is quite 
small. It is usually directed upwards and inwards behind the coeeum, 
and lies coiled upon itself. Its function appears to be the secretion of a 
viscid ropy mucus. 

We thus see in the anatomical and physiological relations of the coeeum 
strong predisposing causes of many morbid conditions. Among these the 
most frequent are distension and impaction of its calibre by hardened 
faeces ; the lodgment of a foreign body or intestinal concretion in one of 
its pouches or in the appendix, an accident which often excites violent and 
destructive inflammatory action ; and finally localized inflammation of 
one or all of the coats of the coeeum or the vermiform appendix. 

This last condition has received the names of typhlo-enteritis, from 
Tocploq^ blind, and evrspov, intestine ; typhlitis ; and coecitis, from the Latin 
word coeeum, also signifying blind. 

The pericoecal connective tissue is also occasionally the seat of inflam- 
matory action, constituting a condition known as perityphlitis. 

Seat and Character. — Clinical experience and the researches of 
pathological anatomy fully justify us in recognizing the above-mentioned 
morbid conditions, but the question as to their relative frequency and 
importance is still far from being settled. 

By some authorities the diseases of the coeeum are regarded as secondary 
to morbid affections of the appendix, the latter consisting generally in the 
presence of foreign bodies, or of hardened, inspissated mucus, which act as 
the focus and exciting cause of the inflammation of the coeeum. 

It is probable, however, in regard to the simple form of typhlitis, that 
both the coeeum and its appendix are subject to a peculiar localized in- 
flammation, involving all their coats, and due to the temporary arrest of 
some foreign substance or intestinal concretion in their cavity, or to the 
action of the causes to be hereafter considered. It is indeed possible that 
the inflammation excited by the presence of a foreign body may subside, 
whilst the cause still remains arrested in the appendix or one of the 
pouches of the coeeum ; but experience would lead us to infer, that, when 
once inflammatory action has been excited, so long as the foreign substance 
which has caused it remains in contact with the mucous membrane, the 
tendency is usually to produce ulceration and perforation of the coats of 
the bowel. 

We find this same discrepancy of opinion in regard to those cases at- 



CAUSES. 443 

tended with perforation of some portion of the civcum, and the formation 
of an abscesi? in the iliac region. Dupnytren, who was the first to call 
attention to the pathology of these iliac abscesses, attributed them to sup- 
purative inflammation of the periccecal connective tissue, produced in 
many cases by extension of inflammation from the coats of the ca?cum, and 
held that the perforation of the bowel often found in connection, was a 
secondary phenomenon, and was in fact the mode by which the abscess was 
discharged. Inflammation and suppuration of the perictrcal tissue does 
indeed occur as an idiopathic affection, or from extension of inflammation 
from the caecum, but it is of extremely rare occurrence ; aud there can be 
no doubt that nearly all cases of iliac abscess are due to perforative ulcer- 
ation of either the ccecum or appendix. As Bouchut suggests, one proof 
that most cases of non-puerperal iliac abscess are thus due to perforation 
of the caecum or appendix, is afforded by their almost constant occurrence 
upon the right side. Thus of 57 non-puerperal iliac abscesses collected by 
Grissolle, 9 only were on the left side ; while of 26 puerperal ones, 15 were 
ou that side. 

It is necessary, however, to carry this question one step further, and to 
determine, if possible, the relative frequency of perforation of the ccecum 
and of the appendix. It has been supposed, as by Ferrall, that ulceration 
of the coecum is in most cases the starting-point in the development of the 
lesions. But, while we are in possession of a sufficient number of recorded 
cases, 12 of which we have collected, where post-mortem examination hhs 
proved the abscess to have originated in perforation of the ccecum, there is 
good reason to believe that perforation of the intestine is much more 
frequently found associated with disease of the appendix than with ulcer- 
ation of the ca?cum itself. 

Causes. — In addition to the anatomical peculiarities of the ccecum and 
ap|)endix, which must be regarded as predisposing causes of these affec- 
tions, there are other conditions which exert an unquestionable influence. 

The strumous diathesis has been regarded as a predisposing cause of 
diseases of the ccecum and appendix. It does not appear, however, that 
inflammation of these parts is more frequent in strumous subjects, but 
merely that it has a greater tendency in such patients to run on to ulcer- 
ation and perforation of the bowel. 

Age. — The greater irritability and proneness to inflammation which the 
intestinal canal presents in early life, appears to have its effect upon the 
development of typhlitis, since a considerable majority of reported cases 
have occurred under the age of 25 years. This is particularly true of the 
milder attacks, which are not attended with ulceration. Thus, of 38 cases 
of typhlitis at all ages, which recovered without perforation of the bowel, 
20 occurred at or under the age of 25 ; 9 only were in older persons. Of 
these 38, 13 occurred in our own practice, and were aged as foUows: 2 
under six years; 6 between 6 and 12 years; 5 between 12 and 15 years. 
Finally, 19 of the 38 cases occurred at or under the age of 15 years. 
This does not appear to hold true, however, with regard to perforative 
ulceration of the co'cum and appendix. 

We have not met with any ca.-e of perforation of the caecum occurring 



444 DISEASES OF THE CCECUM AND APPENDIX CCECI. 

(luring childhood, but of 25 cases collected from different sources, 13 
occurred after the age of 25 ; 12 at or under that age. Of these 25 cases, 

12 only were verified by post-mortem examination, of which 3 were under 
15 years of age, 2 between 15 and 25 years, and 5 above 25 years. 

Of perforation of the appendix vermiformis, we have met with 3 cases in 
children, aged respectively 4^, 8, and 11 years. Of 25 other cases, col- 
lected from various sources, in which the age is stated, 9 were above, 16 
below 30 years of age. Of these 16, 3 only were under 15 years of age, 
so that, including our own 3 cases, we find 6 cases occurring under 15 years, 

13 between 15 and 30, and 9 above 30 years of age. 

Sex. — The influence of sex has been very variously stated by diflferent ob- 
servers. It appears, however, that males are somewhat more prone to all 
these forms of disease than females. Thus of 39 cases of typhlitis, which 
recovered without perforation of the bowel, 23 were in males ; 16 only in 
females. Of 13 of these 39 cases, which we observed in children, 8 were 
males and 5 females. 

Of 25 cases of perforation of the coecum, 13 occurred in males; 12 in 
females. 

The sex is stated in 27 of 32 cases of perforation of the appehdix. Of 
these, 21 were males ; 6 only were females. Of 6 cases occurring under 
15 years of age, the sex is stated in 5, 4 of which were males. 

Occupation. — Various occupations, especially those involving sedentary 
habits, have been supposed to predispose to these aflfections, as also the 
practice among females of wearing tight corsets. Experience, however, 
has not verified these suppositions. 

Constipation. — A constipated state of the bowels undoubtedly predis- 
poses to these affections by favoring the production of a distended and 
impacted condition of the coecum, even if the presence of the hardened 
fecal matter does not prove the exciting cause of some cases of typhlitis. 
Rokitansky considers this cause so important that he has given the name 
typhlitis stercorals to one form of inflammation of the coecum. 

Exciting Causes. — Cold and Exposure. — The action of these ordinary 
exciting causes has been denied by some observers on account of the fre- 
quent absence of a chill or rigor at the inception of the attack, and the 
development of the local before the general symptoms. It cannot, how- 
ever, be doubted that typhlitis may be idiopathic, and arise from the 
ordinary exciting causes, though the cases are comparatively rare. 

Food. — In several instances the attack appears to have been brought on 
by the use of indigestible or irritating articles of diet, among which may 
be especially mentioned unripe acescent fruits. It has been said that the 
use of oatmeal, which favors the formation of intestinal concretions, is 
also liable to be followed by this disease. It does not, however, appear 
that typhlitis is any less frequent in countries where wheaten bread is 
used, than in those where oatmeal forms a chief part of the food. 

Blows or Exertion. — There are a few cases recorded in which a blow 
upon the abdomen, or a sudden violent strain, appears to have been the 
immediate cause of an attack of typhlitis. 

Foreign Bodies and Intestinal Concretions. — This class, comprising very 



CAUSES. 445 

various substances, certainly forms the most important and frequent cause 
of diseases of the civcum and appendix. 

We cannot be positive as to the amount of intiuence they exert in the 
milder and more tractable cases of simple typhlitis, though it is quite 
probable that many of these are caused by the temporary arrest of some 
foreign substance in the appendix, or one of the pouches of the ca?cum. 
Thus, in a case reported by Dr. Wynn Williams {Lancet, January 25th, 
1862), in a male adult, three mouths after a well-marked acute attack of 
typhlitis, which yielded to judicious treatment, a large intestinal concre- 
tion, having a plum-stone for a nucleus, was passed by the rectum. They 
are, however, the etiicient cause of a large majority of all the cases of per- 
forative ulceration of the coecum and its appendix. 

The diseases of this latter part, however, are far more uniformly de- 
pendent upon the presence of foreign bodies even than in cases of the 
ctecum ; almost three-fourths of all recorded cases of perforation of the 
api>endix having been due to this cause. In 6 cases occurring in chil- 
dren, some extraneous substance was found in the appendix in each one ; 
in 2 a foreign body was present ; and in each of the other 4, an intestinal 
concretion. 

Many of these bodies are true intestinal concretions, having for their 
nucleus merely a nodule of hardened fieces or inspissated mucus. They 
vary considerably in size, the majority of them being about the size of a 
cherry-stone or date-stone, though Habershon mentions having seen one 
as large as a hen's-egg. They are also of very varying consistence, accord- 
ing to Volz, as quoted by Hanbury Smith, constituting three varieties : 
the soft, resembling excrement in appearance and odor, and having a 
nucleus of hardened fecal matter; the semi-hard, of a grayish-brown 
color, consisting of shining concrete layers, with a nucleus which is not a 
foreign body; and the stony, which are of a grayish-white or earthy color, 
and have a surface from which may be detached delicate scales, or which 
is smooth, shining, yellowish-white, or brown and studded with calcareous 
projections. 

Many of these concretions consist of carbonate and phosphate of lime 
united with inspissated mucus. Copland also mentions one which con- 
sisted of cholesterin. 

In addition to these, however, numerous foreign bodies have been found 
in connection with the ctecum or appendix, either free or forming the nu- 
cleu.s of an intestinal concretion. Among these may be mentioned grape- 
seedri, cherry-stones, date-stones, pins, bristles, fragments of glass, biliary 
calculi, and balls of worms, either ascarides or lumbricoids. 

It may not be amiss to remark here, that some intestinal concretions 
resemble, to a marked degree, the seeds or stones of different fruits, par- 
ticularly of the cherry, date, and plum ; and there is no doubt that many 
of the bodies found in the ca*cum or the appendix, and reported as cherry- 
stones or date-stones, have been in reality intestinal concretions. 

Whatever be the nature and origin of these bodies, it is probable that in 
many cases some morbid condition of the mucous membrane of the coecum 



446 DISEASES OF THE CQECUM AND APPENDIX CCECI. 

or appeudix precedes their formation or lodgment, and the development 
of the grave symptoms which often follow. 

As Habershon justly remarks, the ordinary calibre of the appendix is 
so extremely small and so thoroughly lubricated, that it must be very rare 
for any extraneous substance to become impacted in it so long as it re- 
mains healthy, A further argument in favor of this view is the fact that 
the presence of these concretions is attended by the most varying results, 
since very large and irritating bodies have been occasionally found occu- 
pying the cavity of the appendix without having produced any symptoms 
during life, or any inflammation of its surface ; while, on the other hand, 
minute concretions of semi-solid consistence, and apparently unirritating 
in character, have frequently been observed to act as the foci of the most 
serious and destructive inflammatory action. 

Anatomical Appearances. — In the simple forms of typhlitis, the 
mucous membrane of the coecum presents the usual appearances of inflam- 
mation ; the peritoneal investment is also involved, and besides injection 
and opacity of this membrane, there are adhesions formed between folds 
of the intestines. 

When, however, ulceration is present, as often results from th^ presence 
of foreign bodies, or in strumous subjects, it is a matter of the utmost im- 
portance which portion of the coecum is involved, since, as such ulcers 
have a strong tendency to perforate the coats of the bowel, if they occur 
on the anterior part of the coecum, which has a peritoneal investment, 
there is the greatest danger of an escape of the contents of the bowel into 
the peritoneal sac, and the development of rapidly fatal peritonitis. 
Thus, of 10 fatal cases of perforation of the coecum, in which the seat 
of the perforation was determined by post-mortem examination, the an- 
terior wall was involved in 6 instances. If, on the other hand, the ulcer 
be seated on the posterior part of the coecum, where it is attached to the 
iliac fossa by connective tissue, and devoid of a peritoneal covering, per- 
foration is not directly followed by any such unfortunate results. Inflam- 
mation is excited in the pericoecal connective tissue, suppuration ensues, 
and the resulting abscess follows one of several courses, precisely as in 
idiopathic suppuration of the pericoecal tissue. Thus it may reopen into 
the bowel ; may burrow along the sheath of the psoas muscle, and point 
below Poupart's ligament ; or it may discharge in the lumbar region, or 
at any point along the crest of the ilium. 

In one case the iliac artery was opened, leading to speedy death from 
hsemorrhage. 

Occasionally these abscesses discharge themselves by more than one 
avenue, as for instance through the bowel, and in the groin or iliac region 
simultaneously. When, as occasionally happens, the inflammation of the 
coecum passes into a chronic form and the ulcerative process ceases, the ad- 
hesions of the coecum to the iliac fossa become preternaturally dense, the 
coecum itself is contracted, its coats thickened, and the mucous membrane 
almost entirely destroyed, or converted into a retiform and trabecular 
fibroid tissue. Rokitansky has found in such cases the coecum converted 



1 



CASE OF PERFORATION OF THE APPENDIX. 447 

into a slate-colored capsule, with dense parietes, of the size of a ^Yalnut or 
a pigeon's egg. 

The appendix t^enniformis may be the seat of catarrhal inflammation, as- 
sociated with intiammation of its peritoneal covering. Death does not re- 
sult from this condition, but the pathological appearances are probably 
analogous to those found in all cases of localized sero-enteritis. 

When, however, the appendix has been the seat of ulceration, and death 
has resulted before perforation has occurred, its cavity is found distended 
with pus, it5 mucous membrane deeply ulcerated, and in nearly every in- 
stance, a foreign body or an intestinal concretion is present. 

The ulceration of the appendix varies in its position and extent, at times 
being seated at the free extremity, at others occupying the lower third of 
the appendix, which is perhaps the more frequent seat. In regard to its 
size, the ulcer and the subsequent perforation may be either very small, or 
else may involve almost the entire circumference of the appendix. 

Under favorable circumstances, especially if the foreign body is dis- 
charged, the ulceration ceases, and the appendix becomes converted into a 
ligamentous cord, its calibre being entirely obliterated. 

When perforation of the appendix occui-s, the results vary according to 
the degree of local peritonitis which has been excited. If the appendix 
ha^ become strongly adherent at the point where perforation is about to 
take place, this accident may not be followed by the development of gen- 
eral peritonitis. The points to which the appendix generally becomes ad- 
herent, are the ccecum, the anterior abdominal wall, and the right iliac 
fossa. In the first case, the circumscribed abscess which follows the per- 
foration of the appendix will discharge itself though the coecum by eflect- 
ing a perforation of its wall from without inwards, and this is the most 
favorable termination possible. When, however, the appendix has become 
adherent to the abdominal wall or iliac fossa, tlie resulting abscess will 
follow. the course, already described, of abscess from perforation of the 
ccecum. 

It is in this connection that the various abnormal positions which the 
appendix may assume, are of importance, as determining the position in 
which the abscess will point. 

Unfortunately, however, the adhesions are rarely strong enough to cir- 
cumscribe the purulent matters escaping from the appendix, so that these 
generally find their way into the peritoneal cavity, and excite general 
peritonitis. 

We subjoin the histories of 3 fatal cases of perforation of the appendix 
from intestinal concretions, occurring in children, in all of which some 
local peritonitis with adhesions had occurred, but had not sufficed to pre- 
vent the above unfortunate termination. 

Care 1. Intestinal eoncretioyi in the appendix crrri, canning perforaticn ami Jatal 
peritrmitui. — T. D. S., a healthy, well-grown boy, 11 years of age, rose on thr- morn- 
ing of December 25th, I860, apparently quite woll. So<^>n afterwards, however, ho 
complained of pain in the right iliac and lumbar regions, was chilly, and re- 
turned to bed. A dose of castor oil was given him. In the course of the day fever 
c«me on. 



448 DISEASES OF THE CCECUM AND APPENDIX C(ECI. 

Next day he was feverish, with a pulse of 132, a hot and dry skin, and a moder- 
ately furred tongue. The pain still continued, with tenderness and slight disten- 
sion of the abdomen on the right side; there was no vomiting. His bowels had 
been acted upon three times by the oil. Leeches and a poultice locally, and a mix- 
ture of blue pill with rhubarb syrup internally, were ordered. 

On the 27th and '28th, the symptoms were much the same, except that the ten- 
derness and distension increased. The pain was aggravated by coughing, by a full 
inspiration, and by motion, especially of the right leg. The bowels were slightly 
moved by the mixture; no vomiting as yet. His fever continued, but the pulse fell 
to 108, and his skin was somewhat cooler. 

On the 29th he was worse. All his symptoms were aggravated, and vomiting 
set in ; his bowels became confined. Small doses of calomel and opium were given, 
encmata of various kinds were tried, and rhubarb syrup with a little fluid extract 
of rhubarb was perseveringly employed, but without effect. The abdomen now be- 
came greatly distended, exceedingly sonorous, and painful ; the stomach grew more 
and more irritable, rejecting from time to time, towards the last, with a sudden 
spasmodic effort, everything that was taken by the mouth. The bowels were com- 
pletely obstructed, so that repeated injections of various kinds elicited no dis- 
charges, even of flatus. The urine continued to be secreted to the last; and there 
was at times, in spite of the nausea and vomiting, quite a strong desire for milk and 
bread. 

During the last few days wine-whey and beef tea were given in small quantities ; 
and opium by enema and by the mouth was used to allay pain. On the third day 
of the treatment a blister four inches square was applied over the seat of tenderness ; 
but neither this nor any of the other remedies employed seemed to exert the least 
effect upon the course of the disease. 

Death took place on the eighth da}', January 1st, 1861. 

The autopsy was made by Dr. Packard, twenty-four hours after death. Body 
large, muscular, and well formed ; rigor mortis well pronounced. Abdomen only 
examined. 

On making the usual section, several coils of small intestine, very greatly dis- 
tended with gas, and markedly injected, with flakes of lymph here and there over 
the surface, at some points gluing the adjacent coils together, were seen concealing 
the rest of the abdominal viscera. After some search, the colon was found, very 
much contracted, except at the coecum. The ileum was in like manner contracted, 
the narrowing beginning at about the end of the jejunum, which formed the dis- 
tended coils above mentioned. No cause was assignable for the constriction at this 
point; but a little lymph was thrown out here, and it may have been that the bowel 
had been twisted. 

The appendix vermiformis was bound down by peritoneal adhesions. "Within it 
near its origin, was a mass as large as a small bean, but perfectly oval. Just beyond 
this mass, at what seemed to have been its position, was an ulcer extending all round 
the tube, and of a gangrenous aspect. At the distal end of this ulcer was a perfora- 
tion, by which matter had found an exit into the peritoneal cavity. The rest of the 
tube looked as if it had been distended by the pus before the opening was formed. 
After its escape from the appendix, the matter seemed to have caused a circum- 
scribed peritonitis, in addition to the general one already indicated. The adhesions 
bounding this peritonitis had extended up to the liver, the convex surface of which 
was hollowed to a slight depth in an oval shape, the depression being lined by false 
membrane. The whole quantity of the pus was perhaps l^iv. 

The liver was pale in patches, but was not degenerated. Kather too large a num- 
ber of oil-drops existed in a dark, inflamed portion of its substance, just beneath the 
depression above mentioned ; but even here the quantity was not great. The mesen- 
teric glands were swollen and injected over the surface. No other lesions were ob- 
served. 

Case 2. Intestinal concretion in the appendix coed, causing perforation and fatal 



TYPHLITIS. 449 

periioniHs. — C. B.. *t. 4i years, was taken sick with slight fever, pain in the abdo- 
men, some vomiting, consiipuiion, and inflation of the abdomen. With these symp- 
toms there was marked tenderness in the rigiit iliac fossa. After three days the 
bowels were well opened, and the fever subsided ; the abdomen, however, continued 
inflated, and a small but distinct tumor had appeared just inside of the right anterior 
superior spinous process of the ilium. 

He continued to improve, and was apparently much better, but was strictly con- 
fined to bed, when on the ninth day, at 3h p.m., he was seized with severe abdominal 
pain ; symptoms of collapse rapidly appeared, and he died at 2 a.m. the following 
morning. 

At the autopsy an intestinal concretion of the shape and size of a date-stone was 
found in the appendix. The end of the appendix was perforated, and had become 
attached to the anterior wall of the abdomen, where a small abscess had formed in 
the cellular tissue between the peritoneum and the abdominal muscles, evidently 
seeking an outlet through the abdominal parietes. The wall of this had unfortu- 
nately ruptured into the peritoneal sac, and death had resulted in a few hours from 
general peritonitis. 

Case 3. R. P., a healthy girl, aged 7J years, died at the end of the second week 
of a well-marked attack of perforative disease of the appendix vermiformis. 

At the autopsy a large, rounded intestinal concretion was found in the appen- 
dix ccBci, which was perforated, allowing an escape of matter into the peritoneal 
cavity. There was marked general peritonitis, with the formation of a large quan- 
tity of pus. 

Symptoms. — Mere distension of the ccecum by hardened fteces, without 
actual inflammation of its coats, may be attended with constipation, some 
vomiting, and the presence of a somewhat sensitive tumor in the cwcal 
region. According to Copland, when the distension by accumulated 
matters is great, it may, from rising high in the abdomen and pressing 
upon the nerves, vessels, and ducts in its vicinity, occasion numbness and 
cpdema of the right lower extremity, retraction of the right testicle, and 
derangement of the urinary secretion, so as to be mistaken for disease of 
the kidney. 

Inflammation of the innrov.-- membrane only of the coecum, is generally at- 
tended with a moderate degree of fever, slight pain and tenderness in the 
right iliac fossa, and some diarrh(pa, with mucous, offensive stools. This 
condition is not unfrequently chronic, and evinces its presence by no very 
positive symptoms, unless adjacent parts have become involved in the in- 
flammation, or an acute attack of typhlitis supervene. 

TYriiLiTi?-, or inflammation of all the coats of the coecum or appen- 
dix, usually appears suddenly during full health, or it may be preceded 
by .«light intestinal derangement, such as diarrhoea or constipation. 

Pain. — The earliest and most marked .symptom is generally pain in the 
r.'inon of the ca'cum, which appears suddenly, becomes fixed and con- 
stant, rarely remitting, and is L'reatly inf-n a-od by a deep in-j)ir:iti()n or hy 
coughing. 

This pain is attended from the very iir~r with surh exfjuisite tenderness 
on pressure in the right iliac region, that the weight of the bed-clothes 
cannot be borne, and the patient shrinks from the lightest touch. To re- 
lieve this pain the patient lies toward the right side, with the thighs flexed 
upon the pelvis, and any attempt to draw the right leg doWn causes ago- 

29 



450 DISEASES OF THE CCECUM AND APPENDIX CCECI. 

nizing suffering. These local symptoms are usually confined to the right 
iliac fossa, though the entire peritoneum may become somewhat involved, 
and the symptoms of general peritonitis develop themselves. 

Fulness or Tumor. — Owing to the distended state of the bowel itself, and 
to the adhesions formed between folds of the intestines, or in some rare 
cases to an inflammatory effusion behind the coecum in the iliac fossa, there 
is marked fulness or even a well-defined tumor in the right iliac region. 
Frequently there will be merely fulness during the first few days of an at- 
tack, and then a distinct tumor will be developed. In 11 of 39 cases of 
acute typhlitis, recovering without perforation of the bowel, a distinct 
tumor was present. In most of the other cases the condition of the coecal 
region is described as one of fulness or distension. Of these 39 cases, 1 9 
occurred in children under 15 years of age, in only 3 of which a distinct 
tumor is recorded to have been observed. 

Constipation. — The bowels are almost invariably constipated ; in many 
cases very obstinately so. This constipation is frequently associated with 
quite severe tormina and tenesmus, and if the coecum be much distended, 
there may be pain shooting down the right thigh, or numbness and even 
oedema of this part, together with retraction of the right testicle. 

It is important to observe here, that in most cases, when once the consti- 
pation is relieved, and free feculent stools procured, the most threatening 
symptoms of the attack rapidly subside. 

Vomiting nearly always attends in children ; it was present in all of our 
13 cases. It is never stercoraceous, and indeed is rarely troublesome unless 
the constipation is marked, or perturbating treatment has been adopted in 
the beginning of the attack. 

Fever. — The attack is not usually ushered in by any chill or rigor ; but 
marked febrile symptoms soon appear, the pulse becomes accelerated, 
the skin hot, the tongue furred, and the thirst extreme. These symptoms 
usually subside under appropriate treatment after a variable time, gener- 
;ally from four to twelve days ; the bowels are opened freely, the pain and 
tenderness diminish, and the fulness in the right iliac region gradually 
.disappears. 

This description of symptoms applies to acute inflammation both of the 
■coecum and appendix, as there are no well-recognized differences in the 
symptoms of these two conditions. The only probable points of difference 
are, that in inflammation of the appendix the pain is more acute, and the 
thorough evacuation of the bowels is not followed by the same prompt and 
complete relief 

Perforation of the Ccecum. — When, however, perforative ulceration 
is progressing, the symptoms follow a different course. The constipation 
may be relieved and the vomiting cease, but the local symptoms persist, 
until the rupture of the bowel leads either to speedily fatal peritonitis, or 
to the effusion of fecal matter mixed with the products of inflammation 
into the pericoecal tissue. When this latter event occurs, the constitutional 
symptoms soon indicate the occurrence of suppuration, and hectic irritation, 
with rigors or marked chills succeeded by drenching sweats, colliquative 
diarrhoea, rapid prostration and emaciation, with a dry brownish tongue 



PERITYPHLITIS. 451 

and feeble ruoDing pulse, soou appear. Despite the desperate character 
of these symptoms, however, recovery may take place if the abscess points 
externally in the way already described, and does not open into the peri- 
toneal cavity. It is necessary to be aware that the approach of a fecal 
abscess to the surface is not attended with the appearances which usually 
accompany the pointing of an abscess. Thus, instead of the skin becoming 
tense, prominent, and reddish, with a distinct sense of fluctuation present, 
the surface becomes doughy and dark-colored, and upon palpation a dis- 
tinct sense of emphysematous crepitation is often obtained. Upon incising 
such a point, a discharge of fetid gas and grumous matter follows the punc- 
ture, and this peculiarity has more than once led surgeons to believe that 
they had opened a knuckle of intestine. 

Perforative Ulceration of the Appendix. — The symptoms of this 
disastrous condition closely resemble those of perforation of the anterior 
part of the coecum. They are, however, often even more acute, the pain 
is sudden and violent, and a distinct tumor is more uniformly present ; 
while, on the other hand, the symptoms of obstruction of the intestine are 
not so well developed. Constipation and vomiting are not constant in the 
early stage, and at a later period spontaneous diarrhoea may appear, but 
without any favorable result. The perforation of this part is, as already 
said, far more apt to be followed by general peritonitis ; and, indeed, so fur 
as we know, there is but one well-authenticated case on record of recovery 
after this accident, which was published by one of ourselves in the Pro- 
ceedings of the Pathological Society of Philadelj^hia. (See Amer. Jour. Med. 
Sciences, vol. liv, July, 1867, p. 145.) 

Perityphlitis, or inflammation of the pericoecal tissue, when it does 
occur independently of typhlitis, is ushered in by pain, with deepseated 
tenderness in the right iliac region. There is also some fulness of this 
part, but not the formation of a distinct tumor, as may frequently be de- 
tected in typhlitis. There are usually colicky pains in the abdomen, with 
either constipation or diarrhoea, and with a moderate degree of febrile 
excitement. This disease, when judiciously treated, frequently seems to 
terminate in resolution ; when, however, suppuration occurs, the symptoms 
will approximate those given above, and the abscess which forms may dis- 
charge itself externally, into the bowel, or into the peritoneal cavity. 

Duration. — Many attacks of acute typhlitis, when promptly and judi- 
ciously treated, yield on the second or third day ; though the case is often 
prolonged to the ninth or twelfth day, and, in violent attacks, it may be 
many weeks before all local tenderness in the cwcal region passes away, 
and the function of the bowel is again completely restored. 

When perforation of the ccccum occurs, the after-duration of the case 
depc*nds entirely upon the point of perforation. If the ulcer have jhii- 
etrated the anterior wall, general peritonitis is usually excited, and death 
resultfl in less than forty-eight hours. But if, on the other hand, the 
posterior wall be perforated, a fecal fistula may be formed, and continue 
open for very many years. The duration of i)erforative ulceration of the 
appendix varies considerably. In 3 cases in children, observed by our- 



452 DISEASES OF THE CGECUM AND APPENDIX C(ECI. 

selves, the du ration was respectively seven, nine, and fourteen days, with 
a mean of ten days. 

In 11 cases, at all ages, in which the duration is distinctly stated, the 
mean duration was nine days, the extremes being two and a half and 
twenty-nine days. 

Bamberger, however, gives the duration of seven cases, occurring at 
various ages, at from twenty to fifty days, with a mean of thirty-one days. 
It is probable, however, that this last mean is rarely attained in cases oc- 
curring in children. 

Prognosis. — Nearly all cases of simple acute typhlitis, without perfora- 
tion of the bowel, recover under proper treatment. Indeed, there are no 
cases on record of acute typhlitis proving fatal, in which post-mortem 
examination did not show the existence of perforation of the coecum or 
appendix. 

When the coecum has become the seat of chronic inflammation, how- 
ever, death may result, either from the sudden development of acute peri- 
tonitis, without perforation of the bowel, or from such contraction of the 
coecum as finally to lead to obstruction of the intestine. 

When perforation of the coecum does not prove speedily fatal from 
peritonitis, but leads to the formation of an abscess in the iliac fossa, the 
prognosis of the ease depends, in a considerable degree, upon the course 
taken by this abscess. Dupuytren regarded the reopening into the bowel 
as the safest termination of an iliac abscess, and the opening upon the 
surface of the body as almost universally fatal. Further experience has 
confirmed the truth of the first portion of this opinion, but has also 
established the fact, that almost one-half of the abscesses opening exter- 
nally recover. 

Perforation of the appendix vermiformis is invariably fatal, so far as 
our experience goes, if we except the case before referred to, where, in an 
old man about whose past history nothing could be learned, we found the 
appendix converted into a solid fibrous cord, with a small opening, near 
the free extremity, leading to its centre. 

Diagnosis. — The general diagnosis of most of these conditions is not 
attended with much difficulty. We have already mentioned that simple 
excessive distension and impaction of the coecum is sometimes attended 
with severe pain, some tenderness, constipation, and even vomiting, and 
that these symptoms are relieved upon free action of the bowels being 
secured. We do not have here, however, the sudden attack occurring in 
a state of perfect health, as in typhlitis, nor the marked febrile symptoms, 
nor are the local signs in the right iliac fossa, and especially the peculiar, 
exquisite sensitiveness, nearly so well developed. 

Inflammatory diseas'e, in connection with the right ovary, with local 
peritonitis, is unquestionably sometimes mistaken for typhlitis. The local 
symptoms in the former affection are, however, lower down in the abdomen 
than is usual in typhlitis ; there is not the well-defined tumor nor the ob- 
stinate constipation ; and, in addition, there is generally the history of 
some menstrual trouble, or the attack occurs in immediate connection with 
the period of menstruation. 



TREATMENT. 453 

Paiu in the course of the last dorsal nerve may arise from spine disease, 
or, in the course of the genito-crural nerve, from the passage of a renal 
calculus, and, according to Habershon, be confounded with ca^cal disease. 
It is evident, however, that most of the characteristic symptoms of typhlitis 
would be absent, whilst a careful investigation of the case would probably 
educe more symptoms of the existing trouble. 

The diagnosis of typhlitis from intussusception, an affection which pre- 
sents many features of resemblance, will be fully considered in the article 
devoted to this latter disease. 

Ulceration of the ccecum or appendix may be suspected, if the violent 
pain and the exquisite tenderness persist in the right iliac region, after the 
other symptoms of an acute attack of coecal disease, especially the vom- 
iting and constipation, have been overcome. Ulceration of the crecum is 
much more apt to have been preceded by bowel complaint for some time ; 
it is also much more rare than ulceration of the appendix. 

In cases where we are consulted only after perforation has taken place, 
with the production of a fecal abscess, we must endeavor, by obtaining a 
most accurate history of the case, to establish the presence or absence of 
symptoms of inflammation of the coecum at the beginning. And further, 
care must be taken to exclude the following conditions, all of which may 
at times simulate iliac abscess, namely : psoas abscess, or abscess connected 
with caries of the pelvic bones ; abscesses in the walls of the abdomen, 
with local peritonitis, resulting from blows ; suppuration originating in con- 
nection with the right kidney or its enveloj^e ; and finally, some cases of 
disease of the right hip-joint. 

The differential diagnosis of these affections of the coecum and appendix 
from one another is as yet scarcely possible. The following general re- 
marks contain, perhaps, all that can be surely advanced : 

Simple inflammation of the appendix presents symptoms of even greater 
acuteness and severity than those of simple coccitis, and which do not sub- 
side so promptly after the bowels have been freely acted upon. 

In ulcerative disease, both of the coecum and appendix, the symptoms 
also persist after the constipation and vomiting have yielded. 

Ulceration of the ca?cum, however, is rare, and is apt to be preceded by 
symptoms of bowel complaint. Whilst ulceration of the appendix, on 
the other hand, is often terribly acute, advancing from a state of apparent 
perfect health to perforation and death in forty-eight hours; it is also 
much more frequently attended with a distinct tumor in the right iliac 
region. 

Treatment. — The indications for treatment in the acute stage of typh- 
litis are clearly to reduce the local inflammation of the peritoneum and 
intestine, to relieve the pain and tenderness, and to secure free and natural 
action of the bowels. At the same time, all perturbating and strongly 
reducing treatment is forbidden, by the knowledge that the attack is fre- 
quently caused by an irritating foreign body: and that, in a certain num- 
ber of cases, perforation will occur, in which event the only hoj)e of recovery 
often rests upon the adhesions which have been formed during the early 



454 DISEASES OF THE CCECUM AND APPENDIX C(ECI. 

stage, and upon the vigor of the constitution to resist a prolonged and ex- 
hausting process of suppuration. 

Depletion. — The local abstraction of a few ounces of blood by the appli- 
cation of leeches to the ccecal region, should be practiced in acute cases. 
This measure, while it does not seriously reduce the strength of the patient, 
relieves the pain and tenderness, and probably facilitates the action of the 
internal remedies employed. Beyond this degree, however, depletion is 
injurious, or, at least, unnecessary. 

Purgatives. — The experience of all observers agrees in condemning the 
use of powerful, irritating purgatives at any stage of typhlitis. In the 
early stage, they aggravate the pain and inflammation, increase or establish 
vomiting, and frequently fail entirely in their object ; while, on the con- 
trary, the constipation which will resist the strongest, most drastic purga- 
tives, will quickly yield to mild, saline, or vegetable laxatives. 

It is a good plan to combine a small amount of opium with the laxa- 
tive ; since, so far from counteracting its operation, it appears, by allaying 
the intense sensitiveness of the bowel, to promote its painless and thorough 
action. 

Burne recommends highly the following laxative draught, the dose of 
which is arranged for an adult : 

R- — Sodffi Sulphatis, ^j. 

Tr. Opii, gtt. V. 

Inf. Senna3, f^j. 

Ft. sol. S. — Repeat every four hours until the bowels are freely moved. 

We have ourselves been led by experience to rely upon the combination 
of comp. ext. colocynth with opium, given in small and frequently repeated 
doses. Thus, for a child of from five to eight years, the following pill 
may be prescribed : 

R- — Pulv. Opii, ". gr- ij or iij. 

Ext. Colocynth. Comp., .... gr. xij to xviij. 
Ft. mas. et div. in pil. No. xxiv. 
S. — One every three or four hours until free action of the bowels is secured. 

Enemata. — The action of these laxatives may be furthered by the ad- 
ministration of large enemata, which may consist either entirely of tepid 
water, or of water containing a small proportion of some stimulating or 
laxative substance, such as soap, molasses, or castor oil. In cases where 
the irritability of the stomach precludes the administration of laxatives by 
the mouth, enemata become especially important, and at times their use 
will be followed by the most happy results, the irritating contents of the 
caecum being brought away, with almost immediate relief to the most 
threatening symptoms. 

Mercury. — It is difficult to support the practice of giving this drug in 
typhlitis. In the early stage, indeed, when it may be supposed that the 
intestinal canal contains irritating ingesta and secretions, a small dose of 
calomel or blue pill may be administered ; and, in a large number of the 



I 



TREATMENT. 455 

sncoessfiil cases ou record, this was done. It is not, however, at all neces- 
sary. Beyond this, the further use of mercury appears to us injurious, 
since, if it be given until any constitutional efiects are produced, it Tuust 
have a tendency to prevent the formation of those strong adhesions which 
constitute the sole chance of recovery in case of perforation of the appen- 
dix or the anterior wall of the ccecum. 

Opium. — "We have already mentioned the way in which opium is most 
advantageously given in this aliection, in combination with the laxative 
employed. Its use is absolutely called for, and the violence of the local 
symptoms, the pain and exquisite tenderness, form the best guide as to the 
amount required. 

Poultices and Counter-irritants, — In case even the local abstraction of 
blood appears undesirable, resort should be had to the frequent applica- 
tion of mustard plasters or turpentine stupes to the coecal region. Hot 
fomentations or light poultices, to which some sedative substance may be 
added, should be kept constantly applied to the abdomen. 

Vomiting when present, should be allayed by counter-irritation, by 
swallowing small fragments of ice, by carbonated drinks, hydrocyanic acid, 
or any other suitable remedy. 

The diet during the early stage should be fluid, and unirritating in 
character. 

When the persistence of the symptoms leads us to apprehend the pres- 
ence of ulceration, either of the coecum or appendix, all depletory and per- 
turbating treatment should be abandoned, and we should limit our efforts 
to the relief of pain, by the use of opium and the continued application of 
poultices ; to regulating the functions of the intestinal canal, and to the 
sustentation of our patient's strength. 

If perforation has occurred, without the speedy development of general 
peritonitis, our attention should be mainly directed to supporting the sys- 
tem during the long and exhausting process of suppuration which must 
ensue. For this purpose a generous, though digestible diet, with as much 
stimulus as appears necessary, should be enjoined ; and resort may also be 
had to the various tonics, as quinia or the preparations of bark. If a 
tumor forms, and it becomes evident that the abscess is tending to dis- 
charge externally, its approach to the surface should be encouraged by 
poulticing ; and the moment an emphysematous condition of the skin is 
detected at any point, a free incision should be made, and the discharge of 
matter furthered by the introduction of a sponge-tent or a pledget of lint, 
and the application of a poultice. 

In those unfortunate cases where the perforation of the bowel has been 
followed by general peritonitis, all treatment is unavailing. Our main 
reliance must, however, be placed upon the exhibition of opium, and the 
use of counter-irritation. 



456 



ARTICLE VI. 



INTUSSUSCEPTION. 



Definition; Synonyms; Forms; Frequency. — Obstruction of the 
intestinal canal, from one or another of the numerous causes capable of 
producing it, is an accident liable to occur at all periods of life. But the 
variety of it which forms the subject of this article is of rare occurrence 
excepting in early childhood. It has been called ileus, volvulus, miserere 
mei ; but is best known under the descriptive names of intussusception or 
invagination of the intestines. It consists in the passage or introduction 
of one portion of intestine within another, as a small tube might slide into 
a large one, or, to borrow a familiar illustration, as the end of a glove- 
finger may be pushed back upon itself into the glove. This simple invagi- 
nation, however, is not the only element present, for in order that the 
symptoms of intussusception should be produced, it is necessary that the 
included portion of bowel should be so incarcerated and constricted as to 
give rise to more or less complete intestinal obstruction. This has led to 
a very just division of intussusceptions into such as are slight, unattended 
by inflammation, or spasmodic ; and such as are grave, or attended by in- 
flammation and incarceration. The slight form of invagination is found 
very frequently at autopsies of children who have died of other diseases, 
and in whom during life there was no symptom of disturbed function of 
the alimentary canal : it is in all probability produced in the death agony. 

M. Louis states that the greater part of 300 children dying during the 
period of dentition ^t the Salpetriere, had 2, 3 or even 4 volvuli without 
inflammation. 

Baillie, Cheyne, and BilJard speak of such intussusceptions as being 
frequently found at the autopsies of children ; and Burns, as quoted by 
Gorham,^ gives the results of the autopsies of 50 children who had died 
from diarrhoea, in every one of which they were found. This species of 
invagination in children occurs almost exclusively in the small intestine ; 
the invaginated part is usually of no considerable length ; and the very 
slightest traction suffices to restore it. 

The grave form, on the. other hand, differs from this alike in the very 
positive symptoms by which its presence is announced, in the condition of 
the parts involved, and in the part of the bowel aflTected; and as the form 
first mentioned scarcely deserves to be called a disease, it is to the latter 
alone that the following remarks are addressed. 

Frequency. — Although numerous well-authenticated cases of intussuscep- 
tion occurring in adults are on record, statistics prove that it is relatively 
much more frequent during the first four years of life. Thus of 100 cases 

1 Guy's Hosp. Keports, 1st series, vol. iii, 1838, p. 330. 



ANATOMICAL APPEARANCES. 457 

given by Duchaussoy' in which the age is mentioned, there were 31 under 
4 years of age, 6 between 4 and 10 years, and ()3 adults. Smith's- tables 
go to show that " this complaint is rare under the age of 8 months, and 
that the period of greatest frequency is from the third to the sixth month 
of life, the maximum number being at the fourth month." Thus there 
were 11, of the 50 cases collected by him, at the age of 4 months, or 21 in 
all between 3 and 6 months inclusive; 8 from 6 months to 1 year; and only 
18 between the ages of 1 and 12 years. 

We must, however, call attention to the rarity of this disease at any age 
among us ; for although, in the course of a very exrensive practice among 
children in this city, we have met with several well-marked illustrations 
of the various forms and terminations of intussusception, it has been one 
of the rarest occurrences in our experience. 

Anatomical Appearances. — Intussusceptions, anatomically consid- 
ered, may be divided into descending or progressive, and ascending or re- 
trograde, according to the direction which the invaginated portion takes ; 
and into central or lateral, according as the entire intestine, or but one 
wall, is invaginated. Lateral invaginations, however, are exceedingly rare, 
occurring but twice in 137 cases collected by Duchaussoy. 

Excepting when invagination occurs as a complication of some other 
affection, it is almost invariably of the descending form. Thus, of Du- 
chaussoy's 137 cases, only 16 were retrograde, all of them being compli- 
cated ; and Haven gives but 3 instances of ascending intussusception out 
of 59 cases. 

It is a matter of considerable importance to determine what is the most 
frequent seat of intussusception in children. Rilliet and Barthez^ declare 
that in infants the small intestine is almost never the seat of intussuscep- 
tion, but that ordinarily it is the lower end of the ileum which is invagi- 
nated into the large intestine. The reasons for this are found in the ana- 
tomical conditions of the intestines- in infancy: the adhesions of the cnecum 
to the right iliac fossa being much more limited and less powerful than in 
later life ; and the muscular coat of the coecum being but slightly developed 
in childhood, a circumstance which must also tend to favor the passage of 
the lower end of the ileum through the valve. 

The statistics of Duchaussoy and Smith confirm this opinion ; as of 31 
cases of simple descending intussusception in children under 4 years of age, 
collected by the former, the large intestine alone, or both the large and 
small, formed the intussusception in all but 4 cases; and Smith states that 
he has found no exception to Rilliet's remark, as regards early infancy. 
In children above the age of 2 years, fatal invagination in the small in- 
testines may occur in rare cases. In a few cases also, the ileum has pre- 
gerve^l its normal relations to the ileo-ccecal valve, the cfccum being the 
first part inverted, and drawing after it the lower end of the ileum. 

* Ducbnu&soy, Mem. de I'Acad. de 31 ed., vol. xxiv, p. 97 (New Syd. Soc. Year- 
Book, 1863, p.* 294). 

' Smith, Sutistics of Intussusception in Children (Am. Jour. Med. Sci, vol. 
xliii, 1862, p. 17). 

' Ma), des En^nt^, 2^me ed., torn, i, p. 806. 



458 INTUSSUSCEPTION. 

An intussusception, then, is made up of three folds of intestine : 1st, The 
inner, or contained part, which in descending intussusceptions is always in 
the natural direction ; 2d, The middle, which is a reflection of the inner, 
and passes in a direction contrary to the intussusception ; and 3d, The 
outer, containing part or sheath, which is in its natural position, and in 
the direction of the intussusception. We find, therefore, the mucous mem- 
brane of the middle and outer parts in apposition ; and the peritoneal in- 
vestment of the middle and inner parts in contact. 

The amount of intestine invaginated and the condition of the parts de- 
pend, in great measure, upon the duration of the case. If death takes 
place early, only a small portion of the ileum may have passed the valve; 
but as the case progresses, the tenesmus or the active peristaltic action of 
the outer part, brings down more and more of the ileum with its accom- 
panying mesentery, until finally, the constriction of the ileo-coecal valve 
preventing the descent of any more of the ileum, the coecum is inverted 
and forced into the ascending colon. This in turn may be invaginated in 
the descending colon and rectum, until not unfrequently a portion of the 
invaginated intestine protrudes from the anus. In rare cases, the whole 
invaginated mass descends into the intestine below, thus forming a double 
intussusception of great thickness. It has occurred, in a few rare cases, 
that the amount of constriction was so slight that the intestine remains per- 
vious to a certain extent ; so that life has been protracted for many weeks, 
and death has finally ensued only from exhaustion. But ordinarily the 
parts are in the following condition : the intestine above the point of con- 
striction is distended with gaseous and fecal contents, and more or less dis- 
colored from congestion of its walls. It is rare, however, to find any evi- 
dences of enteritis either here or in the intestine below the intussusception, 
which is generally pale and contracted. The invaginated portion itself, at 
the upper part, where it seems to plunge into the containing portion of the 
intestine, presents a series of concentric circular folds. The walls of the 
bowel thus incarcerated are thickened and infiltrated ; their serous invest- 
ment either deeply injected or discolored by congestion and ecchymosis, so 
as to be of a deep blackish-red color ; and frequently evidences of local 
peritonitis are present. The mucous membrane in cases of short duration 
may be merely thickened and injected, but more frequently it is turgid 
from congestion, ecchymosed in points, and shows the effects of violent in- 
flammation by its unequal roughened surface, presenting either ulcerations 
or grayish false membranes. The capillaries of the constricted portion be- 
come greatly distended, so that, especially in young children, in whom the 
vascular rete of the intestines is remarkably rich, whilst the tissues are 
delicate and yielding, they frequently rupture, filling the invaginated in- 
testine with blood, and producing bloody discharges. 

If the case is protracted and the powers of life sufficient, when treatment 
has not sufficed to reduce the intussusception, nature endeavors to effect a 
cure by eliminating the invaginated portion. The incarcerated bowel be- 
comes gangrenous, a line of separation forms, union and cicatrization take 
place between the part of the bowel above the intussusception and the upper 



ANATOMICAL APPEARANCES. 459 

part of the containing intestine, and the iuvaginated portion is discharged 
per anum. This process of elimination is extremely rare in infants ; but 
it is stated by Rilliet to be the ordinary method of cure in children in their 
second infjincy. In 59 cases reported by Haven/ of all ages, discharge of 
the intestine per anum took place 12 times, with recovery in all but two 
cases. The average length of intestine passed in these cases was 23^ 
inches : in the two fatal cases, the portions passed were respectively 39 and 
44 inches long. The earliest age at which we have met with this process of 
cure, is at 13 months in a case reported by M. Marage. 

In the report of the Proceedings of the Pathological Society of Loudon, 
vol. xiii, a specimen is described by Dr. Hare, where this process had 
taken place. The patient was a female, 41 years of age, and her death 
resulted from tubercular disease three months subsequently to the passage 
of the sphacelated bowel, " which was 6\ inches in length, of a very dark 
purplish-gray color: it formed a perfect cylinder, but the intestine was 
turned inside out, the exterior of the specimen, as voided, being the mu- 
cous membrane, and the interior of the cylinder being the peritoneal 
covering of the intestine." 

At the autopsy, at the point where the invaginated portion had been 
separated, about fifteen inches above the coecum, the line of union was 
found running obliquely across the intestine, " but the union was so per- 
fect that it could scarcely be detected except by holding up the intestine 
between the eye and the light, when the thinness of the intestine clearly 
pointed out the line or seam where the union had taken place. Exactly 
at the point of union the intestine was notably narrower than natural ; but 
the intestine above this point was a little dilated." 

We have jecently had an opportunity, through the courtesy of Prof. A. 
Stille, of studying a specimen in which a similar process of cure had been 
effected. The patient was an adult, who died of some chronic disease, and 
no history could be obtained of the occurrence of the attack of intestinal 
obstruction, or of the discharge of the sphacelated portion of bowel from 
the anus. The specimen, however, presented appearances which left no 
doubt that invagination of a portion of the ileum had occurred, that the 
invaginated portion had sloughed away, and that union had taken place 
between the intestine, just above the intussusception, and the upper part 
of the sheath, so a.s to preserve the continuity of the bowel. The exter- 
nal surface presented a marked constriction encircling the intestine due 
to the entrance of the upper part of the bowel into the sheath. There 
was a layer of organizx'd lymph investing the peritoneum at the line of 
junction, and firmly uniting the two serous surfaces. Upon laying open 
this part of the ileum, a narrow rira of indurated tissue, evidently the al- 
tered intestinal wall, projected downwards into the intestine from the line 
of constriction, and formed, as it were, a perforated diaphragm across the 
calibre of the bowel. 

We thus see that even when the slough is cast off, and the patient re- 
covers from the intussusception, the cure is not always permanent, since in 

» Haven on Intestinal Obatruction, Amer. Med. Sci., vol. xxx, 1855, p. 351. 



•i60 INTUSSUSCEPTION. 

a small proportion of cases there may be serious contraction of the bowel, 
caused by the ensuing cicatrization. 

In addition to the modes of recovery already adverted to, namely, the 
reduction of the intussusception either by the movements of the bowel 
itself or by the remedial measures adopted, and the elimination of the in- 
vaginated portion, there is still a third mode possible, in which the intestine 
remains invaginated, but by agglutination of the outer folds, becomes per- 
vious, and undergoes such atrophy and contraction as not to interfere 
materially with the functions of the bowel. Rilliet and Barthez, as well 
as other Continental authors, speak of this as of occasional occurrence, but 
we have not found any well-authenticated cases recorded. 

There are few morbid changes found in intussusception excepting those 
pertaining to the intestines. It is, however, worthy of mention, that in 
some cases the invaginated mass appeal's to produce serious compression of 
the large vessels of the abdomen. 

Causes ; Age. — We have already given the statistics which prove that 
intussusception is relatively very much more frequent during the first four 
years of life, the period of maximum frequency being between the third 
and sixth mouths. It is very rare before the age of three months. All 
forms of invagination, however, do not occur with equal frequency at these 
various ages. During early infancy, for the anatomical reasons already 
assigned, the almost invariable seat of the invagination is the lower end 
of the ileum and the upper part of the large intestine ; while, after the 
age of two years, invagination of the small intestine alone, though still 
veiy rare, may occur. 

Sex. — All statistics agree in giving a majority of males over females, at 
least in the proportion of 2 to 1 ; while in some tables the proportion is as 
high as 7 to 1 ; thus Rilliet and Barthez collected 25 cases, of which 22 
were boys. 

Previous Condition. — In by far the majority of cases, intussusception in 
the infant occurs as an idiopathic affection, appearing during perfect health. 
In children over one or two years of age, however, it is much more apt to 
be preceded by some disturbance of the alimentary canal, as constipation, 
diarrhoea, dysentery, or even by symptoms of imperfect obstruction of the. 
intestines. 

Intussusception may also occur during the course of other diseases, as 
in a case quoted by Rilliet from Legoupil, where the invagination ap- 
peared during the progress of variola ; the child, 4^ years old, recovered. 

Exciting Causes. — E.vternal violence, as blows upon the abdomen, or sud- 
den jerking of the child's body, as in tossing it in the arms, are assigned 
as the probable exciting cause of a certain number of cases. It has 
been supposed, also, that violent fits of coughing or screaming, or strong 
straining at stool, have produced invaginations, especially in very young 
children. 

Improper alimentation and sudden changes of diet appear to act quite 
frequently as efficient causes ; thus in a case reported by Gorham, occur- 
ring in a healthy infant of four months old, the only assignable cause was 
the administration of panada for three days preceding the attack. It is, 



SYMPTOMS. 461 

however, frequently impossible to assign any plausible reason for the sud- 
den production of severe intussusceptions. 

Gniuting, however, the presence of any of these causes, the question still 
remains as to the exact mechanism of the invagination. According to 
Gorham, " it is necessary to the production of an intussusception that there 
should be either: 1st, A contraction of the part to be intussuscepted ; or 
2d, A dih\tation of that part which is to be the outer fold ; or 3d, A 
natural and sudden inequality of calibre of some portion of the Intestinal 
tube. The first of these conditions may be produced by spasm ; the second 
by flatus; whilst the third is always present at the termination of the 
ileum in the ccecum." It is at this point, accordingly, that intussusception 
most fre(|uently occui-s, and, from the anatomical arrangement of the parts 
making it very difficult for restitution to occur, puts on its most dangerous 
and fatal characters. 

The invagination having once begun, its increase and persistence are 
probably due to the active peristaltic action of the outer fold, aided by the 
spasmodic contractions of the diaphragm and abdominal muscles, Causing 
the powerful tenesmus so frequently observed. 

There is one more question in regard to the etiology of this affection, 
about which various opinions have been expressed ; whether, namely, en- 
teritis holds the relation of cause or effect to intussusception. Rilliet and 
Barthez appear to us to have given it its true importance in stating that 
it sometimes plays one part and sometimes the other. We have already 
seen that, though in many cases intussusception occurs suddenly in full 
health, there are a sufficient number of instances where the attack has 
been preceded by symptoms of intestinal irritation or inflammation, to 
make it clear that at times enteritis acts as a predisposing or determining 
cause. And, on the other hand, the pathological anatomy of the disease, 
showing the inflammation of the bowel to be limited to the immediate 
vicinity of the invagination, and to be the more intense as the constriction 
is tighter, proves that enteritis frequently appears as a result of intussus- 
ception. This becomes especially evident in those cases where the disease 
has been caused by external violence, and where after death the above 
conditions have been noticed. 

Symito3is; Duration; Terminations. — The principal symptoms of 
intussusception are furnished by the gastro-intestinal apparatus ; and, to- 
ward.s the termination of unfavorable cases, by the nervous system. We 
have seen that a considerable diflference exists in the seat of the invagina- 
tion at different periods of childho<jd, and in examining the symptoms we 
find a corresponding disparity, according as the intussusception occurs in 
the first infancy, under the age of two years, or in the second infancy, 
between the second and sixth year. These points of difl'erence will be 
mentioned as each symptom is di.scu.s»ed. 

The most important and characteristic symptoms are: vomiting, con- 
stipation, and bloody discharge from the anus ; abdominal pain, tenesmus, 
and protrusion of the intestine, the presence of a tumor in the abdomen, 
and tympany. 

Vomitinf/ is an almost constant symptom, being present in about 05 per 



462 INTUSSUSCEPTION. 

ceut. of the cases. Very rarely the gastric disturbance amounts only to 
nausea, but nearly always vomiting set^ in early in the attack and persists, 
despite all treatment, until either the invagination is relieved, when it 
promptly ceases; or until the approach of death. Quite frequently it 
ceases a day or two before the fatal event occurs. The matters vomited at 
first consist of the ingesta, the stomach rejecting everything taken into it ; 
soon, however, they become mixed with mucus and bile. In very young 
children it is rare for stercoraceous vomiting to occur, but in those who are 
above two years of age it may occasionally be present. In Smith's 50 
cases, it occurred in three at the respective ages of 3, 6, and 11 years. 
. The condition of the bowels is generally one of obstinate constipation, 
so far as the passage of fecal matters is concerned. It is not unusual for 
one natural abundant stool to occur after the intussusception begins, but 
this is succeeded by constipation. It is only in those very rare cases 
where the invaginated portion remains pervious, that a small amount of 
fecal matter finds its way into the stools. 

The discharges which, however, do take place almost invariably in in- 
tussusception in children are due to the rupture of the capillaries of the 
constricted bowel, and consist of blood mixed in varying proportions with 
mucus and serum. It is rare for the blood to be so deficient that the dis- 
charges resemble the gelatinoid mucous discharges of dysentery, merely 
streaked and tinged with blood, whilst, at times, the blood is in such ex- 
cess as to appear pure, and to constitute a true intestinal haemorrhage. 
This symptom, the true value of which was first recognized by Gorham 
and Clarke,^ is of more uniform occurrence in children under two years, 
on account of the greater ease with which the intestinal capillaries give 
way in infancy. Thus of 26 children under one year of age, bloody evacu- 
ations occurred in 23, usually several times in the twenty-four hours ; in 2 
of the 26 there is no record of this symptom, and in 1 only is it recorded 
as absent. In case No. 2, of Mr. Gorham's table, a child of 3^ months 
passed within a few hours more than a teacupful of fluid blood. In older 
children, on the other hand, bloody discharges occur less frequently; thus 
Smith records 18 cases of invagination between one and two years, in only 
6 of which it is stated that there were bloody motions. 

We have already mentioned the various ways in which recovery takes 
place, and when elimination of the invaginated portion is about to occur, 
which is almost exclusively limited to cases occurring in the second in- 
fancy, the stools become highly fetid, contain more or less blood, are 
blackish or brownish in color, and are soon accompanied by the discharge 
of the slough. The interval elapsing between the inception of the attack 
and the discharge of the portion of bowel, varies considerably in different 
cases, but seems to be less in childhood than in adult age. Thomson states 
that in adults the elimination takes place in the majority of cases within 
thirty days ; and in one of his cases it occurred as early as the sixth day. 
In children the interval rarely exceeds twelve days ; and the average of 

^ London Lancet, January, 1838. 



II 



SYMPTOMS. 463 

all recorded observations would seem to fix about nine days as the usual 
time. 

Abdominal pain is among the earliest and most constant symptoms at 
all ages. During the early part of the attack, it appears in paroxysms ; 
and may be detected even in the youngest children, by the violent par- 
oxysmal screaming, and contortions of the limbs and trunk. At the com- 
mencement, the abdomen is generally relaxed, supple, and indolent; and 
this condition may remain until death, perhaps because the constriction in 
some eases is not complete and allows the passage of gas. But, after a few 
days, there is apt to be more or less continuous pain and soreness on pres- 
sure in the part of the abdomen corresponding to tlie invagination, due to 
the local enteritis and peritonitis. This may or may not be accompanied 
by tympany and diffuse tenderness of the abdomen ; but, as a general rule, 
intussusception in very young children is not attended by the great dis- 
tension and marked symptoms of general peritonitis which frequently ap- 
pear in intestinal obstruction in adults. In children over two years of age, 
the abdominal symptoms are more apt to indicate peritonitis. In a con- 
siderable proportion of cases, tenesmus occurs and adds much to the suffer- 
ing. It does not appear so early as the abdominal pain, and generally 
ceases a few days before death. 

Tumor. — It would appear natural that when a considerable intussuscep- 
tion has taken place, the knot formed at the point of obstruction should be 
readily detected through the abdominal walls. And yet the cases on rec- 
ord show that this tumor is recognizable in not more than two or three out 
of every ten cases. When it can be detected, it is generally found in the 
left iliac region, varying in size from a walnut to a large goose-egg, and 
giving the sensation of a solid, but doughy and compressible mass. It is 
ordinarily quite movable, and percussion elicits a dull note over its position. 

Another symptom depending upon the displacement of the intestine, to 
which considerable importance ha,s been attached in the diagnosis of in- 
vagination in the adult, is a depression of the abdomen at a point cor- 
resjKjnding to the displaced intestine, and a fulness at the corresponding 
point on the opposite side. Experience has shown, however, that but little 
value can be attached to this sign in young children, on account of its 
great rarity. 

We have seen that the presence of a tumor in the abdomen is far from 
an invariable sign of intussusception, and the same remark applies to the 
profnmon of the invaginatetl bowel from the anus, a symptom to which very 
different diagnostic value ha.s been attached by different authors. It is 
stated by .«f>me to be almost never present, but we have found it recorded 
particularly in six of Smith's cases, the same number in which an abdominal 
tumor was prei*ent in the same series; and in three other cases, altliouL'h 
no tumor protruded from the anus, the invaginated mass was readily felt 
by examination per rectum. 

When the bowel protrudes, it forms an oVjlong tumor, at times even two 
iuches in length, much congested from the constriction, and smeared with 
bloofl and mucus. 

When we pass from these positively diagnostic symptoms, we find little 



464 INTUSSUSCEPTION. 

elsewhere characteristic of the disease. The tongue is normal until in- 
flammatory action sets in, when it often becomes dry and brown; the ap- 
petite is impaired or absent, and the thirst is generally but moderate. 
Rilliet and Barthez call attention to the importance of this last symptom 
in a diagnostic point of view, as well as to the fact that the emaciation is 
usually not so marked as in other acute diseases of equal duration and 
severity. 

The amount of febrile action is generally slight in infancy ; the surface, 
cool at first, may at times become hot, or is alternately hot and cold, 
and as death approaches remains continuously cold. Tiie pulse soon be- 
comes frequent, though small and feeble. There is no marked disturbance 
of respiration. 

In older children there is apt to be more febrile action, the skin being 
hot until late in the attack, and the pulse frequent and more full. The 
physiognomy of the little patient is greatly altered from the commence- 
ment of the attack. The eyes are dull and languid, sunken in their orbits, 
and surrounded by discolored areolae ; the countenance is expressive of the 
most profound prostration, so as to have elicited a comparison to the physi- 
ognomy of cholera patients. 

Almost all cases, at whatever age, present symptoms of marked disturb- 
ance of the nervous system, as great restlessness, indescribable malaise, 
sharp cries, and, toward the close of the case, profound prostration. But 
in infancy, in addition to these symptoms, the case is more apt to present 
an attack of convulsions, either as one of the earliest symptoms, or toward 
death, alternating with coma. 

Duration. — It is necessary to distinguish here between cases occurring 
during extreme infancy, when we cannot hope for elimination to take place, 
and those in more advanced childhood. In early infancy, when the attack 
is about to take a favorable turn, the symptoms usually yield in from two 
to four days, owing to reduction of the invagination. In fatal cases, death 
occurs within five days, as the rule. In some cases, however, where the 
constriction was not complete, life has been prolonged even for six weeks. 

In second infancy, where the constriction is complete, and the result 
fatal, death occurs within seven or eight days in the vast majority of cases. 
But when elimination is to result, the case is more protracted, and complete 
recovery is postponed to the third week. Thus, in 7 cases out of. Smith's 
statistics, which resulted favorably by sloughing, the ages were 5, 6, 6, 9, 
11, 12, and 12 years respectively; and the separation of the invaginated 
portion took place between the ninth and twelfth days, with an average of 
nine and a half days. After the discharge of this, which is soon followed 
by the fetid, brownish-black stools already described, the symptoms rapidly 
disappear, and in one or two weeks the cure is complete ; so that, if we can 
carry a patient, advanced beyond the first infancy, through the first week 
of the attack without too much exhaustion, we may each day look for the 
discharge of the invaginated bowel, the restoration of the function of the 
intestines, and ultimate recovery. 

Terminations. — We have already described the favorable modes of ter- 
mination, namely, by the subsidence of the intussusception, either spon- 



PKOGNOSIS — DIAGNOSIS. 465 

taneously or as the result of treatment; by restoration of the calibre of 
the bowel by sloughing of the invaginated bowel, and union and cicatriza- 
tion of the divided edges ; and linally, by agglutination of the outer layei*s 
of the invaginated portion with subsequent thinning and atrophy, thus 
rendering the intestine pervious, although the intussusception remains. 

In those cases in whicii death takes place very early, as on the first or 
second day, it is frequently produced by cerebral congestion or an attack 
of convulsions. In the majority of cases, however, it occurs somewhat 
later, and is preceded by a state of collapse. Even in those cases where 
the constriction is not at first complete, and where there are daily feculent 
evacuations for a time, death is apt to occur from exhaustion, or from the 
invagination becoming more extensive and symptoms of complete obstruc- 
tion arising. 

Prognosis. — A single glance at the character of the lesion and the 
accompanying phenomena, suffices to assure us of the grave nature of 
intussusception, and of the impotence of all ordinary methods of treatment 
against it. In young infants, indeed, where the strength of the system 
cannot be expected to hold out until elimination occui-s, intussusception 
is almost invariably fatal. In a single instance only has recovery by elimi- 
nation been noticed so early as the end of the first year. In a few cases, 
where the symptoms were well developed and threatening, they have sub- 
sided and the infant has recovered, apparently from spontaneous reduc- 
tion of the invagination. 

We must not, however, forget that during the early stage of this affec- 
tion the diagnosis is somewhat doubtful, since young children frequently 
present symptoms of obstructed and loaded intestine, such as a distended, 
hard abdomen, constant unnatural straining, with evident suflering, and 
yet are entirely relieved after the administration and operation of laxa- 
tives. 

Not to refer now to the recent cases of successful abdominal section, a 
considerable number of cases of cure of undoubted intussusception, by 
means of inflation, have also been reported even at this early age ; so that, 
when treatment is instituted soon after the appearance of the symptoms, 
the case is not absolutely hopeless. In older children, that is to say, above 
three years of age, the prognosis is much less unfavorable, since treatment 
offers a certain amount of hope, and there is always the prospect of the 
occurrence of elimination of the invaginated bowel, if the strength of the 
patient has been sustained during the first week. 

Even after elimination has taken place, however, the prognosis should 
still be somewhat guarded, as the slightest indiscretion in diet may, either 
by the development of flatulence or by the escape of irritating, undigested 
panicles into the intestine, cause a rupture of the recently formed cicatrix 
and speedy death. 

DiAGNr>iis. — Intussusception has been, until recently, regarded by all 
authors as an affection of obscure and doubtful diagnosis. With the light, 
however, which has been thrown upon this subject by the labors of Clarke, 
Gorham, Smith, and especially Rilliet, the diagnosis in the great majority 
of cases can be made with precision. It is true, however, as conceded by 



466 INTUSSUSCEPTION. 

Rilliet, that " very rarely in early infancy, more frequently than later, 
there are certain cases of invagination impossible to distinguish from other 
forms of intestinal obstruction ; and that at all periods of childhood the 
diagnosis presents many difficulties." 

With what diseases, then, could we confound this affection, occurring, 
as we have seen, suddenly in perfect health ; attended by obstinate, though 
rarely fecal vomiting ; by marked constipation, but with frequent bloody 
discharges ; by paroxysmal abdominal pain and tenesmus ; by the presence 
of a tumor, generally in the left iliac region ; by the protrusion of the in- 
vaginated bowel from the anus ; and by profound prostration and disturb- 
ance of the nervous system. It is to be remembered, iudeed, that this 
group of symptoms, so characteristic when viewed together, are rarely all 
present ; and that with the exception of the vomiting, constipation, and 
bloody discharges, there is no single symptom which is not more frequently 
absent than present. There are, nevertheless, a sufficient number present 
in nearly every case to enable us to form a diagnosis. 

The diseases which may most readily be confounded with intussuscep- 
tion are, 1st, impaction of the intestine with hardened f^ces ; 2d, typhlitis 
or perityphlitis ; 3d, cholera infantum ; 4th, dysentery ; 5th, intestinal 
haemorrhage ; 6th, the various forms of internal strangulation ; 7th, peri- 
tonitis. 

1st. When an accumulation of fecal matter takes place in either the 
coecum or sigmoid flexure, the case may present many symptoms similar 
to those of intussusception. There is frequently such gastric and intes- 
tinal irritation, as to lead to occasional vomiting and paroxysmal abdom- 
inal pain ; the bowels are constipated, and there is frequent and strong 
tenesmus, so as often to cause protrusion of the bowel. In addition to 
these symptoms, a well-defined tumor is present in one or the other iliac 
fossa. 

These cases, however, often have presented symptoms of intestinal dis- 
turbance for some time previous to the attack ; the vomiting is rarely so 
constant as in intussusception; the tumor is quite painless and has a pecu- 
liar doughy consistence ; bloody discharges from the bowels are very rare ; 
and we do not notice the profound prostration which exists in well-estab- 
lished invagination. During the early stage of the case, however, the 
diagnosis is doubtful ; and when we have reason to suspect the presence of 
fecal accumulations, we must await the result of the administration of lax- 
atives and laxative enemata, before deciding upon the nature of the case. 

2d. Inflammation of the coecum, appendix vermiformis, or of the peri- 
ccecal connective tissue, is attended with fulness or a well-defined tumor 
in the right iliac fossa, with vomiting, constipation, and occasionally tenes- 
mus, with distension of the abdomen and pain radiating from the right 
iliac region. 

There is, however, a marked degree of fever, and the symptoms of local 
peritonitis appear early in the case ; the patient assumes a characteristic 
position, with the thighs flexed upon the pelvis, and the right iliac fossa 
is the seat of exquisite tenderness, so that the slightest pressure cannot be 
tolerated. The vomiting and constipation are not so marked and obsti- 



DIAGNOSIS. 467 

nate, and excepting in those cases which have been preceded by dysenteric 
symptoms, there are no bloody discharges, and as we have remarked 
above, the tumor or fulness is in the right iliac fossa ; whereas when this 
sign is present in intussusception, it usually occupies the left iliac region. 

3d. In cholera infantum, the vomiting is often incessant ; the stools are 
frequent, with painful tenesmus ; the abdominal pain paroxysmal, and 
occasionally the intestine protrudes from the anus. It is almost impossible, 
however, to mistake this affection for intussusception, if we remember that 
it is almost always accompanied by fever, with insatiate thirst, and prompt 
and extreme emaciation ; that the abdomen is without tumor, and rarely 
distended until towards the close of the case, and that the stools, instead 
of being bloody, are large and fluid. 

4th. Dysentery frequently offers a close resemblance to intussusception 
so far as the characters of the stools are concerned, as they are often small 
and bloody, or muco-sangu indent. But we do not see in dysentery the 
sudden inception, the rapid progress, the obstinate vomiting, the moist 
tongue and moderate thirst, which characterize intussusception. 

5th. We have seen that occasionally the amount of blood passed by 
stool in intussusception is very great, and constitutes a true intestinal 
hseraorrhage ; thus in the case reported by Marwick,^ it amounted to a 
large teacupful of pure blood. 

Intestinal hiemorrhage is a very rare occurrence during childhood, but 
has been noticed in children in connection with polypus of the rectum, 
especially by Mr. Bryant ; in typhoid fever, or the hiemorrhagic form of 
-ome others of the exanthemata, and in the course of purpura. The absence 
of the other symptoms of intussusception, however, and the presence of 
the local or general symptoms peculiar to these various conditions, will 
?erve to render the diagnosis easy. 

6th. Other forms of internal strangulation, such as those produced by 
a diverticulum from the intestine compressing it, by the adhesion of the 
vermiform appendix .so as to constrict the bowel, or by a contraction of 
the calibre of the bowel, produce symptoms so identical with those of 
intu«su.«ception in second infancy, when the affection more nearly resembles 
-final obstruction in the adult, as to render diagnosis impossible. The 
nee of an abdominal tumor, the occurrence of bloody stools, or the 
protrusion of the constricted bowel from the anus, would be the only diag- 
nostic signs. 

7th. Peritonitis, when diffuse, presents a few symptoms in common with 
intu*su.«ception ; as the vomiting, constipation, abdominal pain and tender- 
ness ; and when the inflammation of the peritoneum is localized, there is 
in addition a well-defined sensitive tumor, which soon appears as the result 
of the inflamraator}' action. The diagnosis here rests upon the greater 
frefjuency of the vomiting in intussusception, the more obstinate constipa- 
tion with bloody discharges from the bowels; the paroxysmal nature of 
the abdominal paio, with less tenderness ; the less degree of fever, the 

* London Lancet, July, 1846. 



468 INTUSSUSCEPTION. 

moist tongue, slight thirst, quiet respiration, and only moderately acceler- 
ated pulse. 

Treatment. — There is no special plan of treatment for intussusception 
deserving the name oi preventive, owing to our ignorance of any symptoms 
which can be definitely regarded as the precursors of the invagination. 
The fact, however, that various derangements of digestion, such as pain 
upon going to stool, diarrhoea, or constipation alternating with diarrhoea, 
have been occasionally noticed to precede the attack, should be an addi- 
tional motive to urge us to meet these symptoms by the most assiduous 
attention to the hygiene of the child, and to the regulation of its alimen- 
tary functions. 

The curative treatment may be divided into three classes : the medical, 
mechanical, and surgical treatment. 

Medical. — Depletion is strongly contraindicated by the tender age of the 
patients, and by the necessity of preserving the vital powers; since elimina- 
tion, which affords the principal chance of recovery, does not occur until 
after the eighth day. In order, however, to relieve the engorgement at the 
point of constriction, without reducing the strength of the patient, it is ad- 
visable to apply a few leeches or cups to the abdomen, and preferably to 
the right iliac region, unless a tumor can be detected, when, of course, they 
should be applied over its seat. 

Purgatives were formerly strongly advocated by most authors ; the one 
most generally advised being quicksilver, which was given with a view of 
overcoming the obstruction by its great weight and fluidity. The use of 
this agent is now, however, universally reprobated. 

In regard to other and less mechanical purgatives, there is still some 
difference of opinion. 

During the early stage of the attack, before the symptoms of intussus- 
ception are very positively developed, we should advise the administration 
of a mild but thorough laxative, such as castor oil, in conjunction with 
large laxative enema ta. If, however, at the end of twenty-four or forty- 
eight hours, the administration of these remedies, aided by the local deple- 
tion, has failed to produce an evacuation from the upper bowel, these 
measures should be abandoned, and recourse be had to means of calming 
pain and nervous disturbance, and to the sustentation of our patient. 
Among the remedies best calculated to allay the pain, the tenesmus and 
the nervous irritability are: opium, in doses proportionate to the intensity 
of the pain ; warm anodyne poultices applied to the abdomen, and warm 
baths carefully given. These latter are especially serviceable when the 
symptoms of nervous disturbance are marked, even amounting, as they oc- 
casionally do, to general convulsions. 

In endeavoring to sustain the child's strength, attention must be paid to 
the vomiting, which is generally so severe as to prevent any nourishment 
being retained. The remedies of most service against this are counter-irri- 
tants to the epigastrium, opium, hydrocyanic acid, carbonated water, small 
pieces of ice kept constantly in the mouth or swallowed whole. 

Nutritious eneraata may also be tried, but are rarely retained. 

The mechanical treatment consists in the injection of fluids or air into the 



k 



TREATMENT. 469 

bowel iu such quantities as to distend it; and in the introduction of a h\rge 
sound, with the view of pushing up the invaginatod portion of intestine. 
The fluids generally used have been either tepid water or warm gruel, in- 
jected forcibly into the bowel, until the sudden cessation of resistance in- 
forms us of the reduction of the intestine. We have already seen that the 
seat of intussusception in the child is almost invariably the lower end of 
the ileum, which passes into the coecum and is there constricted ; and, 
when we reflect that it has been frequently demonstrated that if fluid be 
forcibly injected into the large bowel, the ileo-ca^cal valve will rupture 
before any fluid is allowed to j)ass into the ileum, it is evident that we can 
in this way exert a most powerful pressure upon the invagiuated intestine. 
Experience shows that this procedure is frequently successful, even in cases 
where all medicinal treatment has proved unavailing ; and there are now a 
sufficient number of such cases on record to render a resort to it proper. 
The fluid may be introduced by an ordinary syringe, or better by a Bow- 
ditch's syringe, the limbs being held together so as to prevent as far as 
possible any reflux. It has been recently suggested by Simon that hydro- 
static pressure might be employed to force fluid into the bowel. For this 
purpose a glass funnel attached to a long india-rubber tube terminating 
in an olive-shaped plug is used. The plug is inserted in the anus, and 
the funnel is held on a level with the body, and water poured in until it is 
filled. The funnel is then gradually elevated, and more and more water 
poured in to replace that which is forced by the hydrostatic pressure into 
the bowel. Owing to the gradual and uniform increase in pressure thus 
brought about, extreme distension of the entire colon can thus be produced. 
We have recently employed this mode of treatment with most gratifying 
success in a very severe case of an infant of 6 months of age. 

^ir, also, both on account of its great elasticity and mobility, as well as 
the great facility of its introduction in sufficient quantity, is to be highly 
recommended. Indeed, inflation was advised by Hippocrates as a remedy 
in intussusception, but until within the past forty yeai-s does not seem to 
have been much practiced. Two cases of obstruction of the bowels, oc- 
curring in adults, successfully treated by inflation, are reported in the 
American Journal of Meflical Sciences, for 1883: one by Dr. Janeway, of 
New York ; the other, which, however, was transcribed from the Gldsrjoiv 
Medirnl Journal, for 1831, by Dr. King. The following year, in the Bos- 
ton Medical and Surgical Journal, December 15th, 1834, Dr. J. Wood 
publi.*hed a ca^, also in an adult, where death seemed imminent, but 
where the obstruction was readily overcome by inflation, and the patient 
recovered. Since then, this remedy has been frequently employed in in- 
tuisusception in children, and with such good results, that it may fairly be 
said that the prognosis of this affection is less grave since the introduction 
of this remedial measure. To obtain the best result.e, inflation should be 
employed early in the case, before any considerable amount of adhesive 
inflammation has taken place between the sheath and the contained intes- 
tine. The air is readily introduced by a pair of ordinary' bellows; the 
nozzle being inserted well into the rectum, and inflation continued until 
the obstruction yields. The return of the invagiuated intestine is some- 



470 INTUSSUSCEPTION. 

times attended by a clearly audible sound, a species of crack, but it never 
gives any pain, and has generally seemed to afford relief. The complete 
restoration of the calibre of the intestine is proved by the copious feculent 
stools which frequently come away soon after the inflation. 

A third mechanical means for restoring the displaced intestine has 
been recommended by Dr. Nissen, and consists in pushing up the invagi- 
nated portion by means of an oesophageal sound protected by a sponge. 
This proceeding would probably be readily accomplished, if the intussus- 
ception occurred far down in the large intestine; but it would appear very 
difficult to replace in this way an invagination as high up as the ileo-coecal 
valve. Dr. Nissen, however (in the Journal de Canstatt, quoted by Rilliet 
and Barthez), gives two cases in which he succeeded in pushing up the in- 
testine into the ascending colon, with complete relief of the symptoms of 
obstruction. There are also a few other cases of cure, by this means, upon 
record in medical literature. 

The surgical treatment, consists in the performance of the operation of 
gastrotomy, finding the invaginated portion of bowel and reducing it by 
gentle traction. When, in our last edition, Ave expressed ourselves in favor 
of this operation under certain circumstances, there existed much diversity 
of opinion on the subject and many authors condemned it. Their disap- 
proval was based upon the grounds of the great difficulty of ascertaining 
the exact position of the intussusception ; the difficulty of restoring the 
invaginated intestine even if found ; and finally upon the dangers of the 
operation. 

We have seen, however, that in the majority of cases the invaginated 
mass will be found in the neighborhood of the left iliac fossa ; the lower 
end of the ileum having traversed the coecum, ascending and transverse 
colon, and these parts being successively inverted ; that in a certain pro- 
portion of cases a tumor is readily detectable ; and further, that some idea 
as to the seat of obstruction may be obtained from the distance to which 
enemata appear to penetrate. So that in a considerable proportion of the 
cases, we have the means of localizing the point of constriction, with a 
certain amount of definiteness. 

In regard to the difficulty of reducing the invaginated parts, authors 
differ greatly. It has been remarked, that even if the equivocal and un- 
certain nature of the symptoms of volvulus were not sufficient to deter us 
from undertaking the operation, the state of the invaginated parts would 
entirely banish all thoughts of such an imprudent attempt ; since the dif- 
ferent folds of intestine become so agglutinated to each other that they can 
hardly be withdrawn, even after death. 

Rilliet and Barthez {loc. cit.), however, conclude from their anatomical 
researches, that in the majority of cases the disengagement of the intes- 
tines is very easily accomplished ; and accordingly they declare that, "after 
employing medical treatment during three or four days, and after having 
made several attempts at inflation, we should not hesitate to perform gas- 
trotomy." 

The great danger of the operation is, of course, apparent, but should 
hardly be considered an objection, when we consider the fatal nature of 



I 



TREATMENT. 471 

this affection. Nor have the results of operation been such as to destroy 
hope. In addition to several successful operations previously recorded, 
the only 3 cases out of the 57 collected by Haven, in which gastrotomy 
was performed, terminated favorably. ^lore recently, also, the operation 
has been performed several times by ditierent operatoi*s (J. Hutchinson, 
Howard Marsh, Legge, and others), and with such encouraging results as 
to fully justify us in repeating our former advice in regard to its perform- 
ance. 

To sum up our remarks upon this subject : after having tried for two 
or three days the medical and mechanical means recommended, without 
success, we must forbear and decide whether to trust the case to nature, 
with the hope of elimination of the invaginated bowel occurring, or to 
resort to gastrotomy. And in this decision, the circumstances of each 
case must be taken into account ; for if the case has not yet progressed 
so far that adhesive inflammation has certainly taken place, and if we are 
able to detect the exact seat of constriction by the presence of a tumor, 
the operation certainly has strong arguments in its favor, and should not 
be hastily rejected. 

In those cases which have been trusted to nature, and when elimination 
has fortunately occurred, we must treat the child, during this crisis, with the 
utmost care. The diet must be rigidly regulated, and the child kept in 
absolute repose. Nor must we relax these precautious for several weeks, 
and allow either indigestible food, or too large a meal of even the most di- 
gestible articles ; since death has been several times known to follow this 
imprudence, from a rupture of the imperfectly formed cicatrix. 



CLASS IV. 

DISEASES OF THE NERVOUS SYSTEM. 

GENERAL REMARKS. 

It is a very common opinion, both in and out of the medical profession, 
that this class of diseases occasions a much larger number of deaths in 
childhood than any other. Indeed, many persons suppose that, be the 
primary disease what it may, nearly all children who die, die, as it is said, 
by the brain. It appears, however, from an examination of the bills of 
mortality for this city, that this opinion is not well founded. During the 
five years from 1844 to 1848 inclusive, the number of deaths from diseases 
of the nervous system was less than from diseases of the digestive system, 
and though larger than those from diseases of the respiratory organs, not 
so much so as the popular notion would seem to warrant. The number of 
deaths from diseases of the nervous system was 3970; from diseases of the 
digestive system, 4204 ; and from affections of the respiratory system, 3376. 
M. Barrier, whose observations were made at the Children's Hospital in 
Paris, says {loc. cit., t. i, p. 35) that, setting aside cases in which the ner- 
vous symptoms were probably only sympathetic of some other coincident 
disease, the cerebro-spinal affections were few in number in comparison 
with those of the thorax, abdomen, and senses, including amongst the 
latter the eruptive fevers. He states {loc. cit., p. 34) that affections of the 
thorax constituted two-fifths of all the cases of disease, those of the abdo- 
men and senses each one-fifth, and of the nervous centres only a tenth. 
M. Barrier, after combating the opinion so generally entertained, that 
disorders of the nervous system cause the death of the greater part of the 
subjects who die before puberty, says {loc. cit., t. ii, p. 233) that there is 
only one circumstance that in part justifies this opinion, which he opposes 
" not as false, but as exaggerated," and this is, that the affections alluded 
to are almost always of a dangerous character, that they are beyond the 
resources of art, and that they furnish a very considerable relative mor- 
tality. He says that, according to his experience, the mortality in diseases 
of the cerebro-spinal system has been as sixty-eight in a hundred, while 
in those of the thorax, senses (including the skin), and abdomen, it was 
respectively as forty-eight, forty, and thirty-two in a hundred. 

Before beginning the consideration of the particular diseases of this 
class, we are desirous of stating that we shall be compelled, on account of 
our limited space, to devote attention chiefly tQ those which are most im- 
portant from their frequency or severity, avoiding or merely alluding to 




TUBERCULAR MENINGITIS. 473 

those which are of less cousequeuee, or which occur in childhood merely 
in common with adult life. 

In our earlier editions we divided this subject into two classes, one con- 
taining all the'diseases attended with and dependent upon, some appreciable 
alteration of the nervous centres, the second containing those in which no 
such alteration exists. We have since discardetl that arrangement, princi- 
pally on account of the minute researches of histologists during the past few 
years, which have all gone to prove the existence of positive and definite 
tissue-changes in many diseases previously regarded as purely functional. 



ARTICLE I. 

TUBERCULAR MENINGITIS. 

Definition ; Synonyms ; Frequency. — This disease is characterized 
by violent cerebral symptoms, dependent upon the existence of tubercular 
granulations in the pia mater, as the essential anatomical lesion ; accom- 
panied, in the great majority of cases, by coincident inflammation of that 
membrane, by softening of the central parts of the brain, by effusions of 
serum into the ventricles, and in many instances by tubercular deposits in 
other organs. Formerly tubercular meningitis, simple acute meningitis 
independent of tuberculization, and simple dropsical effusion within the 
cavity of the cranium independent of inflammation, were confounded to- 
gether under the single term of acute hydrocephalus or water on the brain. 
It has been shown, ho'wever, that a large majority of the cases of acute 
hydrocephalus of authors are, in fact, cases of tubercular meningitis, and 
more recent researches have further shown that most of the remaining 
cases are in reality due to the altered condition of the blood, called 
uraemia, and are independent either of any material lesion of the brain or 
of the presence of an excess of serous fluid in its cavities. 

The term acute hydrocephalus ought to be therefore restricted to the 
single condition of sudden serous effusion in or around the brain, indepen- 
dent of any inflammation ; a condition which only occurs in connection 
with the causes of general dropsy, and especially with renal disease, and 
is, indeed, merely the most rare form of internal dropsy, and, as such, not 
to be regarded as a separate disease. A description of the symptoms of 
this condition will be found in our remarks upon the renal complication 
of scarlatina. 

There can be no doubt that tubercular meningitis is of rather frcrjucnt 
occurrence, though it is difficult to obtain statistic.*? which will enable us to 
form anything like an accurate idea upon this point. M. Barrier doc. 
cit., t. i, pp. 34, 36) states that during the periml in which his observations 
were carried on at the Children's Hospital in Paris, there occurred 576 
medical cases of all kinds. In this number there were only 10 cases of 
tubercular meningitis, whilst there were 83 of pneumonia, 48 of pleurisy, 



474 TUBERCULAR MENINGITIS. 

24 of typhoid fever, 48 of measles, etc., etc., showing the first-named dis- 
ease to be much less frequent than many other aifections. We may also 
form some idea of its frequency in proportion to other diseases, by a ref- 
erence to the work of MM. Rilliet and Barthez (lere edit.), "who report 33 
cases of tubercular meningitis, against somewhat over 245 of pneumonia, 
174 of bronchitis, 111 of typhoid fever, 167 of measles, and 87 of scarlet 
fever. We are of opinion that it is not of frequent occurrence amongst 
the easier classes of this city, since we have met with less than 60 cases in 
private practice in the course of thirty-five years. We observe it more 
frequently, however, in our large children's hospitals, and from what we 
have been told by other practitioners, it seems probable that it is much 
more common among the destitute classes, and particularly the blacks, 
who crowd the southern parts of the city, and who suffer to a great extent 
from tubercular and scrofulous diseases. It is, however, impossible to ob- 
tain accurate information in regard to the frequency of the disease in this 
city, in comparison with other affections of the brain, from a reference to the 
bills of mortality. Thus during the year 1874, with a total mortality of 
16,254, there were 8349 deaths among minors ; of these, 143 are recorded 
as from hydrocephalus (tubercular meningitis), 382 as from cephalitis, 
211 as from congestion of the brain, 83 as from brain disease undefined, 
and 654 from convulsions. It cannot be doubted that a considerable 
number of cases of tubercular meningitis are included under these latter 
vague headings. 

Predisposing Causes. — MM. Eilliet and Barthez (2eme ^dit., t. iii, p. 
511) state that the disease is very rare in the first year of life ; that it be- 
comes notably more frequent in the second year, but that it is between two 
and seven years of age that it occurs with the greatest frequency. After 
this, it diminishes, they say, rapidly from eight to ten, and especially from 
eleven to fifteen years of age. The influence of sex has not been determined, 
but it appears probable that boys are somewhat more subject to it than 
girls. It has been clearly shown by the observation of various writers that 
the disease usually attacks delicate children, and especially those born of 
parents who are either themselves laboring under tuberculosis, or in whose 
families that diathesis has existed to a greater or less extent. Of the 31 
cases that have come under our own observation in which we have pre- 
served notes of the disease, in 20, one of the parents either had phthisis at 
the time, or died of it subsequently ; in 3, one or the other parent came of 
a tuberculous family, though in these both parents were living at the time 
in seeming good health ; in 4, no trace of tuberculosis could be found in 
the parents or in their families, and in 4 the history of the parents or of 
their families could not be traced out. It is not uncommon for several 
children in a family to die of tubercular meningitis. Under these circum- 
stances, it has nearly always been ascertained that the parents, or some of 
the immediate relations, have either died of tuberculous or scrofulous dis- 
ease, or shown unequivocal signs of one of those diatheses. Thus, 4 of the 
above-mentioned 20 cases occurred in two families, in one of which the 
father is since dead of phthisis, and in the other the mother has long been 
ailing with inactive tubercle of the lungs, and slow caries of a bone, in all 



ANATOMICAL LESIONS. 475 

probability of tuberculous oripn. It may fc^llow other diseases, and has 
been observed particularly alter measles and other fevers, and after the 
suppression of eruptions. 

]M. Barrier {op. cit.j t. ii, p. 379) explains, and we think with good show 
of reunion, the causes of the disposition on the part of the tubercular dia- 
thesis in cliildren to localize itself in the brain, as well as the dispropor- 
tionate violence and extent of the inflammatory action in comparison with 
the degree of the tubercular lesion, by the physiological conditions of the 
Dervous system in early life, which are those of great functional energy and 
nutritive activity. The affection, though much more frequent in childhood, 
is by no means peculiar to that period of life, and we have met with, in 
addition to the cases above referred to, a number of cases occurring in the 
adult, and presenting the same general clinical symptoms and anatomical 
lesions. 

As to the excitiufj causes, nothing positive is known. The disease has 
been supposed to be brought into action by falls and blows upon the head, 
by violent moral emotions, and by exposure to the sun. These causes, 
however, are all of doubtful influence. 

Recent pathological investigations have established the fact that, in 
many case, the development of true miliary tuberculosis of the cerebral 
membranes, or of other tissues, is connected with the previous existence of 
foci of cheesy degeneration, as in an enlarged lymphatic gland, a patch of 
unabsorbed pneumonia exudation, or otherwise. Undoubtedly such a con- 
dition exerts its power of infesting the general system, and leading to the 
development of tuberculosis, especially when, there exists a hereditary pre- 
disposition to that disease. In a number of instances, we have been able 
to trace the origin of tubercular meningitis to this cause. 

Anatomical Lesions. — The tubercles which constitute the essential 
anatomical element of the disease are very rarely found upon the free sur- 
face of the arachnoid, but almost invariably beneath that tissue, or in the 
meshes of the pia mater. They usually appear as more or less opaque 
gray granulations, the so-called miliary tubercles, and may generally be 
seen through the arachnoid, scattered about in the shape of small, rounded, 
or flattened bodiei?, of grayish or yellowish-gray color, and varying in size 
from two-fifths to four-fifths of a line. When the finger is passed over the 
arachnoid above them, they may be usually felt as little granular bodies. 
Their size, however, varies very much, and they are in some cases so small 
and 8o closely resemble in color the .surrounding parts, that it requires a 
careful search to detect them. They vary also greatly in number, being 
in some ca.«e8 thickly scattered over a considerable extent of the pia mater, 
while in other cases but two or three can be discovered on each hemi- 
aphere. 

Frequently they can be detected with most ease upon the processes of 
pia mater which dip down between the convolutions, so that if we fail to 
find any granulations upon the surface, we should always strip ofl' the pia 
mater and carefully examine these processes. Upon a careful examina- 
tion of the arrangement of the miliary tubercles, it will often be observed 



476 TUBERCULAR MENINGITIS. 

that they are clustered about the small arterioles of the pia mater, and 
evidently follow in their distribution the branches of these vessels. 

These granulations are not found upon all portions of the brain equally 
in cases of tubercular meningitis. On the contrary, they are rarely pres- 
ent upon its convexity or lateral aspects, while they are uniformly present 
at the base, and especially about the optic chiasm and the fissures of 
Sylvius. 

Upon microscopic examination of one of these granulations, its tissue is 
seen to be composed of numerous oval cells, with a single nucleus, though 
there are also some larger cells mixed with these which contain several 
nuclei. In many instances, as has been observed by Cornil,^ Hayem,^ Bas- 
tian,^ and ourselves,* the tuberculous granulation will be seen to envelop a 
small arteriole, whose calibre is obstructed at the point of its development. 
There is also marked proliferation of the cells of the perivascular sheath 
of the vessel for a varying distance on either side of the granulation, and 
it is highly probable that it is from these cells that the granulation has 
been developed. 

We think it probable that some of the granulations may also be devel- 
oped from the cells of the connective tissue which holds together the 
vessels of the pia mater. 

These miliary tubercles precede the occurrence of the inflammatory 
changes in the meninges described below, and sometimes it happens, in 
very acute cases, that the only lesions discoverable consist of a few gray 
granulations scattered in the meshes of the pia mater. It is not probable, 
however, that they exist any great length of time without giving rise to 
meningitis, since they are usually found associated with more or less abun- 
dant inflammatory exudation, which surrounds and often conceals them. 
The chief seat of this inflammation, as of the tubercular deposition, is the 
pia mater; the arachnoid membrane being, as a general rule, affected 
only to a slight extent. That membrane sometimes, however, contains a 
very small quantity of clear or turbid serurn, in its cavity. Its surface is 
often dry and viscid, and in some instances its whole tissue is opaque and 
thickened. But it is chiefly in the pia mater that are found the evidences 
of severe inflammation. In order to detect these changes, it is necessary 
to examine the membrane not merely upon the surface of the brain, but 
to tear it off*, so as to bring into view the portions which dip in between 
the convolutions, and which often exhibit the greatest amount of morbid 
alteration. The inflammatory lesions vary between mere vascular injec- 
tion, infiltration with clear, turbid, or gelatinous liquid, and abundant 
formation of lymph. When the inflammation has gone beyond mere san- 
guine injection, it is marked by infiltration of the membrane with turbid, 
whitish, or sanguinolent serum, with pus, or with whitish or yellowish 
lymph. These products are, like the tubercular granulations which they 
imbed and often conceal, most abundant at the base of the brain, about 



1 Arch, de Phys. Norm, et Path., 1868, p. 98. 

2 Etudes sur les Diverses Formes d'Encephalite, Paris, 1869. 

3 Edin. Medical Journal, 1867, p. 875. 

4 Trans, of Biological and Micros. Section of Acad, of Nat. Sci. of Phila., 1869. 



ANATOMICAL LESIONS. 477 

the peduncles of the cerebrum, the optic chiasm, and in the fissures of 
Sylvius ; like these granulations also, the products of the iniiammation are 
most marked along the track of the bloodvessels. In this respect the dis- 
ease differs from simple meningitis, in which the results of inflammation 
are usually more abundant and well marked upon the convexity than at 
the base. The pia mater, which, in a healthy brain, can be readily de- 
tached from the surface of that oriran, becomes, in cases of meninijitis, 
particularly in those which are violent, more or less adherent, so that in 
tearing it oft' portions of the ciueritious substance, which is itself softened, 
come with it. The proper tissue of the membrane is thickened and indu- 
rated, the degree of thickening depending on the amount of infiltration. 

After the changes in the pia mater, the most important anatomical fea- 
ture is efliusion within the ventricles. This was formerly thought to be the 
essential lesion of the disease, but recent researches have shown that it is 
absent in some instances which have followed in all respects the ordinary 
course of the malady. According to M. Barrier, effusion cannot be sup- 
posed to exist unless the ventricles contain from one and a half to two 
ounces of fluid, whilst Rilliet and Barthez assert that the normal quantity 
is a few grammes (about a drachm). The quantity in this disease is very 
variable ; sometimes there are only a few drops or a teaspoonful, while in 
other instances it amounts to three ounces and a half, or much more. It 
may be so large as greatly to distend the ventricles, rupture the soft com- 
missure of the thalami, and even the septum lucidum, diminish consider- 
ably the thickness of the hemispheres, and flatten the convolutions against 
each other. In such cases the effused fluid passes through the membrane 
of the ventricle and infiltrates into and softens the substance of the brain, 
80 that the latter becomes almost of the consistence of thick cream. The 
characters of the fluid vary in different cases. It is white, perfectly limpid 
and transparent, or may be turbid, either from being secreted in that con- 
dition or from holding in suspension albuminous or purulent flocculi, or 
portions of the broken-down walls of the cavity. In some rare instances 
it is sero-sanguinolent. Rilliet and Barthez remark that the effusion which 
coincides with tubercular meningitis is different from that which accompa- 
nies tubercles of the substance of the brain. In the former it takes place 
rapidly, is turbid, exist.s in smaller quantity, and constitutes the condition 
formerly called acute hydrocephalus. In the latter it is secrcteJ slowly 
and in considerable quantity, dilates the walls of the cranium, and consti- 
tutes one form of chronic hydrocephalus. 

The brain itself presents various morbid alterations. The whole organ 
often seems enlarged, so that the dura mater appears distenrlcd, and when 
the latter is cut into, the cerebral substance protrudes in the form of a 
hernia. At the .same time the convolutions are observed to be pressed 
against each other, and the anfractuf^ities seem to have disappeared. 
The compression of the brain depends either upon the di^tcnrling action of 
the ventricular effusion, or upon sanguine turgescence of the organ. In 
most cases, but not in all, there is evident congestion of the cerebral sub- 
stance, shown by a more or less abundant dotted redness, and sometimes 
by a general rosy tint of the medullary, and vivid redness of the cortical 



478 TUBERCULAR MENINGITIS. 

portion. Softening of the substance of the brain is of common occurrence 
in connection with the other lesions. We have already spoken of the soft- 
ening of the walls of the ventricles where there is much effusion, and which 
in some cases appears to result from the macerating influence of the fluid. 
In many other cases, however, microscopic examination of the softened 
brain-tissues shows the effects of inflammation in the presence of numerous 
granule-cells, free granular matter, and a disintegrated condition of the 
nerve-fibrils. In addition to this, as figured by Rindfleisch {Syd. Soc. edit, 
vol. ii, p. 312), the proper vessels of the cortical substance of the brain 
frequently present tubercular degeneration of their walls. The lining mem- 
brane of the ventricles also presents abnormal appearances in a majority 
of cases. In some these consist merely in injection with loss of polish and 
transparency ; in others, however, by viewing the surface sideways, we can 
detect a very finely granular condition, as though the membrane had 
been sprinkled with fine sand. Loschner (Aus devi Franz Joseph Kinder- 
spitcde, 1860, Prague), has found this appearance to be due to a prolifer- 
ation of the cells of the ependyma, the minute granulations consisting of 
rounded nucleated cells. In Dr. West's minute analysis of 61 autopsies 
of tubercular meningitis, also, the lining membrane of the ventricles pre- 
sented evidences of inflammation in a large proportion of the cases. We 
have also referred, very cursorily, to the softening which exists under the 
inflamed portions of the membranes, and which occasions adhesion of the 
pia mater to the brain beneath. In the latter cases the softening may be 
either red or white, and does not penetrate more than a line, and often less, 
in depth. 

In addition to the changes already described tubercles of the brain itself 
may be occasionally met with, having no connection with the meninges. 
These are found in various parts of the organ, and differ greatly in size, 
varying generally between that of a millet-seed and hazel-nut, but reaching 
sometimes the volume of a pigeon's or hen's egg, or even that of half the 
fist. 

We have but few words to say in regard to the lesions of other organs. 
It is undoubtedly true that in the vast majority of cases tubercles are found 
in other parts of the body. Of all the cases of tubercular disease observed 
^y Rilliet and Barthez, amounting to 312, in only one was the deposit 
•confined to the meninges (op. ciL, lere edit., t. iii, note, p. 49). M. Valleix 
(op. cit, t. ix, pp. 196, 197), states, that in all the cases, without exception, 
of tuberculosis of the meninges in adults, tubercles exist also in the lungs, 
and that the same is true, in the vast majority of cases, in regard to chil- 
dren. The organs in which the deposit is most apt to exist are the bron- 
chial glands, lungs, mesenteric glands, pleura, and peritoneum. 

Another very frequent lesion is softening of the stomach. This may 
affect only the mucous or all the coats, so that a slight degree of force will 
suffice to tear the organ. Dr. Gerhard (Am. Jour. Med. Sei., vol. xiv, 1834) 
states, that lesions of the stomach existed in six of the ten cases detailed 
by him, and in four-fifths of others not detailed. 

Before quitting this subject, we would call the attention of the reader 
to the fact mentioned by M. Valleix {op. cit, t. ix, p. 214) that all the 



i| 



SYMPTOMS. 479 

symptoms about to be described as constituting the disease under consider- 
ation, with the exception of paralysis, may depend on simple tuberculosis 
of the meninges. Several cases have been cited, in fact, in which the only 
lesion found after death consisted of granulations in the pia mater. No 
traces of inflammation were observed. It is clear, therefore, that the evi- 
dences of the disease, or symptoms, depend not merely on inflammation 
caused by the tubercular deposits, but on the presence of that morbid pro- 
duction. The paralysis, which is one of the important symptoms, depends 
partly upon the inflammatory changes in the brain-tissue itself, and partly 
upon the pressure exerted on the structures at the base of the brain by the 
exudation which forms there. 

Symptoms; Course; Duration. — The disease has been divided by 
authors into different stages, founded on the predominance of certain 
symptoms at particular periods of its course. 

These divisions are all imperfect and unsatisfactory, because the disease 
is in fact a continuous one, and for this reason some writers have avoided 
attempting any classification of the symptoms. We can, however, obtain 
a more faithful picture of the disorder by adopting the division made by 
M. Valleix, which, though arbitrary and imperfect, because of the want of 
a natural line of demarcation, seems warranted by the very great diflJer- 
ences in the character of the symptoms at an early and late period of the 
afllection. We shall therefore describe first the invasion of the malady, 
and then two stages or periods of the symptoms after the disease is con- 
firmed. 

The invasion of the disease may be either insidious or sudden. In a 
large majority of the cases, the onset is preceded by a well-marked pro- 
dromic period. The length of this period varies greatly in different sub- 
jects. Its duration is stated by ^DI. Rilliet and Barthez to be, as a general 
rule, between fifteen days and three months, scarcely ever less, and rarely 
more. During this period, the symptoms presented by the child are those 
which are ur^ually held to be indicative of a failure in the general health. 
The nutritive functions especially show disorder. The appetite diminishes, 
or becomes capricious, there are alternations of constipation and diarrhoea, 
the bo<ly grows thin, the color pales the gayety of childhood disappears, 
and the patient becomes listless, apathetic, and complains of being tired and 
weak; or he is irritable and j)eevish, or too mild and gentle; study and 
exercise both become distasteful, and there is a degree of weakness and 
debility, which, though slight at first, becomes at length so evident as to 
arouse the attention of the parents, or those who have charge of the child. 
If, as not rarely hapixjns, there is a development of miliary tubercles in 
the lungs also, there may be troublesome, dry, spasmodic cough before the 
appearance of cerebral symptoms. Besides these symptoms, there is oftt^n 
very great restlessness at night. The only pain complained of is headache, 
and sometimes abdominal pain. The headache is, in subjects old enough 
to notice and describe their sensations, often a prominent symptom. It is 
not constant, but occurs at intervals, and is sometimes severe, and its re- 
turns fre^pient. Fever is not generally present until after the more [)()sitive 
symptoms have fairly begun, and when present is generally slight and 



480 TUBERCULAR MENINGITIS. 

fugacious. The eraaciatioQ and loss of strength are seldom present to such 
a degree, in the prodromic stage, as to confine the child to the house. On 
the contrary, he continues to amuse himself at times, and to walk as usual. 

The following is a rapid and summary account of the mode of invasion 
in some of the cases that have come under our own observation : 

In one case, in a girl six years of age, the invasion was preceded during 
three months by occasional cough, and irregular attacks of fever, by pro- 
gressive emaciation, pafeness, languor alternating with extreme irritability, 
disinclination to take exercise, and during the latter part of the time by 
partial lameness, and in fact by all the signs of general tubercular disease. 
In another, which occurred in a boy eight years of age, it was preceded 
for several months by frequent complaints of intense headache, especially 
after taking active exercise, and by unusual languor, but no other symp- 
toms. The boy was sent to a boarding-school apparently well, and was 
suddenly attacked there. In fi.ve cases the meningeal symptoms were 
developed in connection with those of phthisis, whilst in an eighth they 
followed a state of general weak health, with dyspeptic symptoms, which 
had lasted for several mouths. In a ninth case, a violent convulsion, 
seemingly dependent on a fit of indigestion,, was followed during four 
months by irregular and diminished appetite, by some loss of strength and 
flesh, and by frequent attacks of severe headache, and at the end of that 
time, by the symptoms which denote inflammation of the membranes. In a 
tenth, after some months of gradual thinning and general debility, a con- 
vulsion occurred, also from indigestion apparently. This was I'ecovered 
from, but a few days afterwards the symptoms of meningitis showed them- 
selves, and followed their usual course. In an eleventh case, occurring in 
a girl ten years of age, there was a mild, almost continuous fever, lasting 
four weeks, and resembling most closely typhoid fever, except that there 
was no diarrhoea and only a very few doubtful rose spots, when severe 
frontal headache, vomiting, slow and intermittent pulse, with drowsiness, 
declared the invasion of tubercular meningitis. In a twelfth, a girl three 
years old, born of healthy living parents, presented for four days the signs 
of gastric catarrh, with, however, unusual irritability of temper alternat- 
ing with a suspicious quiet. On the fifth day, there was just perceptible 
strabismus, after which the case went on in the usual way to a fatal result. 
In a thirteenth, in a girl five years old, of healthy living parents, but with 
tuberculous grandparents on the father's side, the general health failed 
slowly, with loss of appetite and flesh for one month. Then there set in 
lassitude, desire to lie about, with the most petulant irritability on the 
slightest disturbance, occasional vomiting, constipation, loathing of food, 
and gradual conversion of drowsiness into coma, and so on to the end. 
In a fourteenth, a case of general miliary tuberculosis, to which allusion 
has already been made in the article on Hooping-cough, there was a hard, 
spasmodic cough for some weeks, succeeded by an irregular febrile state 
simulating typhoid fever, and lasting some days before the appearance of 
cerebral symptoms. In the remaining cases that we have seen, the inva- 
sion was preceded by much less decided prodromic symptoms. 

After the different phenomena above described as characteristic of the 



SYMPTOMS OF THE FIRST STAGE. 481 

prodromic stage have continued during a variable length of time, the 
disease entei*s into activity, a change which is ushered into by three im- 
portant symptoms: headache, vomifin<j, and en nsfipat ion, to \\\uc\i is added, 
in a large majority of the cases, sliglit aeeeleration of the circulation. At 
the same time the intelligence remains perfect, the strength is not greatly 
diminished, the appetite is not entirely lost, and the thirst is moderate. 

First stage. — The headache, vomiting, and constipation persist and be- 
come more marked. Headache is a nearly invariable symptom in children 
old enough to describe their sensations, and is therefore very important. 
In infants its presence is to be inferred when the child carries its hands 
frequently to various parts of the head, and presses strongly against it, 
and when the head is constantly rolled from side to side. It is generally 
frontal, and is usually referred to a point just over one or both brows. In 
other cases it extends over the whole head. It is commonly severe, so 
that the child when old enough complains of it spontaneously. In the 
case of a girl seven years old, whom we saw, it was so severe that she cried 
frequently and bitterly, begged to have the doctor sent for, and submitted 
willingly to any remedy suggested with a view to its relief. It is thought 
that the acute, shrill cry of the disease, to which the term hydrencephalic 
has been applied, depends on the acuteness of this pain. It usually lasts 
throughout the first stage, and ceases only as the delirium and coma of the 
second stage come on. Vomiting is also a nearly constant symptom. Of 
80 cases collected from different sources by M. Barrier, it was absent only 
in 15, or less than a fifth. This symptom generally makes its appearance 
on the first day, rarely later than the second or third, and lasts two or 
three days, and sometimes longer. In one case that we saw, it lasted 
eleven days, though it was but slight on the tenth and eleventh. The 
matters ejected from the stomach consist of the ingesta, and of mucus and 
bile in various proportions. It is commonly repeated two or three times a 
day. Comtipation is even more important as a symptom than the one last 
named. Of 87 cases it was absent only in 7, according to Barrier. MM. 
Rilliet and Barthez state, however, that it exists at the beginning only in 
about three-fourths of the cases. Where there is diarrhoea instead of con- 
stipation, at the invasion, as sometimes happens, the former symptom 
almost always depends on tubercular disease of the intestine. Even under 
these circumstances, however, the diarrhoea is sometimes arrested, and 
constipation substituted under the influence of the cerebral disease. The 
constipation generally persists obstinately for several days, and then gives 
way uncfer the influence of purgative medication, or is replaced sponta- 
neously by diarrho/a with involuntary stools towards the termination of the 
case. 

In connection with the three important symptoms just described, there 
are others, which, though less characteristic, are of much assistance in 
forming the diagnosis. The child is dull and xad, or excited and irritable 
by turns; he shuns the Ught^ or closes the eyelids and contracts the brows 
when it is thrown upon the face; his hearing becomes painfully acute, so 
that sudden and jarring sfninds distress and irritate him ; the sleep is rest- 
less and disturbed, and accompanied by grinding of the teeth ; and he 

81 



482 TUBERCULAR MENINGITIS. 

utters from time to time, both sleeping and waking, the peculiar shrill, 
sharp, and sudden scream, which seems to depend upon internal pain, 
probably headache, and which has been called by Coindet the hydrence- 
phalic cnj. In young children, those who have not yet learned to put their 
sensations into words, a peculiar, apparently causeless, obstinate peevish- 
ness and positive ill-temper, shown by sudden, sharp crying at any dis- 
turbance, as even the kindness of a father or mother, especially when this 
alternates with sluggishness or drowsiness, and when there is no evident 
disease of a painful or exhausting kind to explain such a state, ought to 
arouse the fears of the physician as to the possible inception of this disease, 
even when there is as yet no vomiting or distinct signs of headache to call 
attention to the brain. The general as well as the special sensibility is 
sometimes but not by any means always, exaggerated at this time. Killiet 
and Barthez met with exaltation of this function only in four of their 
patients. The intellectual faculties remain undisturbed in the majority of 
the cases during the first few days, and this fact, which is. so contrary to 
what might be expected, is one of the utmost importance in the judgment 
of the case. We remember being asked by a little girl seven years old, 
to whom we have already referred, " why it was that she saw double ; why 
she saw two mothers and two doctors ?" At the time when she first asked 
the question there was no perceptible strabismus, but on the following day 
we thought we could detect a deviation of one of the eyes from its proper 
axis, and on the third day the deviation was very marked, though the poor 
child still wondered why she saw two objects instead of one. In another 
case in a boy five years old, there was no disorder of the intelligence until 
the eleventh day, when there was slight delirium alternating with somno- 
lence ; yet it was clear from the first that the attack would prove one of 
tubercular meningitis, from the coexistence of violent frontal headache, 
obstinate vomiting, constipation, slow and irregular pulse, and the absence 
of other local or general symptoms. In only a fifth of the cases observed 
by MM. Rilliet and Barthez was there perversion of the intellectual fac- 
ulties at the invasion. Let us observe, moreover, that even when children 
present some of these disorders early in the attack, they generally consist 
only of slight delirium, dulness of the intelligence, slowness and hesitation 
in answering questions, disposition to somnolence, excessive irritability and 
peevishness of temper, and what is more important and characteristic than 
any of these, perhaps, of a certain expression of the countenance, and par- 
ticularly of the look, which is expressive of astonishment or of the utmost 
indifference. The look is, in fact, fixed or staring, like that of one in a 
mild ecstasy. Even when these symptoms exist, however, at an early 
period, they not unfrequently alternate with the most perfect clearness of 
the faculties, so that the physician in private practice, who sees his patient 
only at long- intervals, and for a few moments at a time, should never ven- 
ture to disbelieve, without due consideration, the account of the mother or 
nurse as to their occasional presence during his absence, even though never 
observable during his visit. We knew this to happen in regard to two 
boys of eight and ten years of age respectively, whose mothers constantly 
insisted to the physician in attendance that during his absence the chil- 



SYMPTOMS OF THE FIRST STAGE. 483 

dren occasionally presented slight delirium, and a wild uncertain expres- 
sion of the countenance, which made them fear that the brain might be 
affected. As the children's intelligence was perfect, however, whenever 
the doctor saw them, he determined that the mothers were fanciful through 
over-anxiety, and ascribed the sickness to a bilious disorder of the stomach. 
After a few days the cases developed themselves, and the boys died with 
every symptom of tubercular disease of the brain. 

AVhen disorders of intelligence do not occur in the early days of the 
attack, they usually make their appearance about or soon after the fifth 
day. 

In this disease, as in acute simple meningitis, the obstruction to the re- 
turn of venous blood through the sinuses produces in both eyes, but especi- 
ally in the one corresponding to the hemisphere where the inflammation is 
most intense, congestion and oedema of the optic papilla and surrounding 
tissue (Bouchut's peripapillary congestion) ; tortuosities and varicosities of 
the retinal veins ; and occasionally thrombosis or rupture of these vessels, 
causing minute hiemorrhages in the retina. In some cases the size of the 
globe is increased, owing to hydrophthalmia. In addition to this, the char- 
acteristic ap|>earances of optic neuritis often become visible. These lesions 
are indeed more frequent in this disease than in simple meningitis, since 
the inflammation and resulting exudation are more apt here to involve the 
base of the brain, and cause a greater degree of obstruction to the circula- 
tion. 

Enlarged experience has convinced us of the high value of these retinal 
lesions in establishing the difl^erential diagnosis of tubercular meningitis. 
It is true that they cannot be regarded as pathognomonic of the existence 
of this disease, and are therefore only valuable as confirmator3'of the gen- 
eral symptoms, still in certain cases the development of the ocular lesions 
before the appearance of the more characteristic symptoms enable the dixig- 
na«is to be made at an earlier date than would be possible without oph- 
thalmoscopic examination ; while in others where the general symptoms 
leave it for the time doubtful whether the case is one of typhoid fever or 
of tubercular meningitis, the use of the ophthalmoscope renders invalua- 
ble aid. 

During the first stage the coloration of the face ought to be noticed. It 
is generally paler than natural, though from time to time a sudden flush 
of redness may be seen to pass over it. The condition of the sens&s is 
natural, except that the acuteness of the eye, ear, and sometimes that of 
touch, are exalted, so that the child avoids the light, starts at sudden or 
loud sounds, and cries when it is touched or moved. The rejtjnration 
becf)mes unequal and irregular, and is interrupted by sighing or yawning. 

Cont'uhionji rarely occur in the first stage. MM. Rilliet and Barthez 
conclude that meningitis without complication of tuberculous disease of 
the cerebral substance, never begins with convulsions. In one of the cases 
that came under our charge, a severe and prolonged convulsive seizure did 
occur, however, on the very first day of the attack of the disease. The 
ruhject of the case was a boy between four and five years old. The death 
took place on the eighteenth day. and the autopsy showed no tubercular 



484 TUBERCULAR MENINGITIS. 

disease of the cerebral substance. It is proper to state, however, that the 
child had eateu on the morning of the day that he was attacked, a most 
unwholesome meal, and it is very possible, as we in fact supposed at the 
time, that the convulsions were caused by the presence in the stomach of 
undigested food. When they do occur in tubercular meningitis, they may 
be limited to the extremities, upper lip, eyeballs, or they may be general. 
Sometimes the child dies in a convulsion. They are generally much less 
important as a symptom, according to M. Valleix, than in simple acute 
meningitis. 

The tongue remains moist ; the appetite is not entirely lost ; thirst is 
moderate ; the constipation continues, unless removed by treatment ; the 
abdomen becomes retracted, so that its walls approach closely to the spinal 
column, and allow us to feel the pulsations of the aorta without using 
more than very slight pressure. The latter symptom comes on gradually, 
and is generally well marked by the sixth day or a little later. MM. 
Rilliet and Barthez regard it as a very important sign, and state that 
they have observed it almost exclusively in cerebral affections. They think 
it depends not upon contraction of the abdominal muscles, but upon re- 
traction of the intestines. We can corroborate by our own experience, 
the evidence of the above authorities as to the value of this symptom. It 
has been very marked in most of the cases that we have seen. 

The state of the circulation is of the utmost importance in forming the 
diagnosis. So true indeed is this, that Dr. Whytt, of Edinburgh, whose 
description of acute hydrocephalus, published in 1768, has been most 
highly commended by all recent -writers as a singular instance of accurate 
observation, makes three stages of the disease, each of which is character- 
ized by the state of the pulse. In the early part of the attack the pulse 
is accelerated, rising to 110, 120, or, according to Whytt, in a few^ cases to 
130 or even 140. At the same time it is neither full nor tense, as a gen- 
eral rule, but rather soft and compressible. This condition of the pulse 
changes, as we shall find, in the middle period of the disease, and again 
shortly before the fatal termination. The heat of the skin is usually 
moderate and sometimes quite natural, at this time, as might be supposed 
from the state of the circulation. Frequently the temperature will not 
during this period exceed 100° to 100.5°, though occasionally marked 
and rapid changes in it are observed. It is especially to be noted that 
the temperature does not follow the regular mode of development so char- 
acteristic of typhoid fever. 

Second stage. — This stage begins about the time the more marked ner- 
vous symptoms show themselves. The headache generally subsides or 
ceases at the beginning of this period and gives place to delirium. This 
occurs usually somewhere between the sixth and twelfth days. The de- 
lirium which occurs has been generally supposed to be always mild and 
calm. MM. Rilliet and Barthez state, however, that in one-third of their 
cases it was intense, and accompanied with cries, agitation, and frequent 
changes of position. In most of the cases, however, it is mild, and is mani- 
fested in older children by their muttering unintelligible words, by in- 
attention to what is going on around them, by an expression of wildness 



I 



SYMPTOMS OF THE SECOND STAGE. 485 

and astonishment, and by their giving hesitating answers to questions. In 
chiklren under two years of age there is no proper delirium. There is, 
however, an analogous condition, which is characterized by disorder of 
the two faculties of attention and perception. The delirium seldom lasts 
more than two or three days, and generally alternates with somnolence, so 
that the child is either dozing and sleeping, talking in its sleep, or fre- 
quently waking with loud cries, and restlessness. The general sensibilityf 
which may have been exaggerated in the early period of the disease, is 
diminished in the early part of the second stage, or about the seventh day, 
and completely abolished towards the end. The face in the second stage 
is almost always pale, or pale and flushed alternately. During this stage, 
and especially during the latter part of it, it is very common to see sud- 
den alterations in the color of the face. Sometimes without any apparent 
cause, but more frequently from disturbances of any kind, as from pain, or 
from external influences acting upon the child, such as moving it, or the 
administration of food or medicine, the face becomes suffused of a more or 
less deep pinkish or scarlet tint, the color beginning faintly at first and 
gradually deei)ening and expanding until it covers the whole face and 
forehead, and then as gradually fading away. It is during this stage also 
that another symptom, which we have often noticed, and to which M. 
Trousseau has called attention, may usually be observed. M. Trousseau 
refers to it as a red line or spot remaining upon the skin of the forehead 
or abdomen when the finger has been drawn across it, and has given to it 
the name of ''tache meningitlque," or "tache cercbrale." We had often re- 
marked, before knowing that M. Trousseau had drawn attention to this 
phenomenon, that the slightest pressure with the finger on any part of the 
face or forehead, caused the appearance at the point of pressure, of a spot 
of a j)eculiar pink or rose color, which, like the flush above referred to, 
began faintly, became more or less deep in tint, remained a few moments, 
and then as gradually faded away. This symptom is undoubtedly due to 
the extreme modification of the innervation of the minute bloodvessels of 
the skin. There is no doubt that it is nearly always present in cases of 
tubercular meningitis, and thus may be said to possess a diagnostic impor- 
tance. We have, however, so frequently met with the same phenomenon 
in cases of typhoid fever, and more rarely in cerebral pneumonia, that we 
must warn against its being regarded as a pathognomonic symptom of 
tubercular meningitis. Occasionally contractions pass over the features, 
giving rise to grimaces, after which the countenance resumes its expres- 
sion of indifference and stupor. The eyelids are generally only partially 
closed, and between them the globes of the eyes can be seen to oscillate 
and move in various directions, as though by some automatic force. 

A.S the case progresses, the nervous symptoms become more and more 
marked ; somnolence gradually deepens into coma ; the delirium becomes 
less and less frequent ; and the child no longer observes what is going on, 
nor answers questions. As the somnolence and coma increase, various 
lesions of motility make their appearance, consisting, in order of frequency, 
of paralysis, which is generally partial ; contraction with rigidity of the 
limbs; stiffness of the muscles of the back of the neck, causing retraction 



486 TUBERCULAR MENINGITIS. 

of the head ; stiffness of the trunk ; spasmodic closure of the jaws ; car- 
phologia ; subsultus tendinum, and convulsions. The paralysis is almost 
always partial and of very limited extent, affecting, for instance, the jaw, the 
orbicularis muscles of the eyelids, the levator of the upper eyelid, the tongue, 
or one side of the face. It is very rare to see one of the limbs paralyzed. 
Contraction with rigidity of the muscles is an important symptom, but is 
not always present. When it exists it generally appears at an advanced 
period of the attack, commonly between the seventh and thirteenth days, 
and is usually partial. It may affect either the extremities, back of the 
neck, trunk, or inferior maxilla. It is seldom permanent, but after lasting 
one or two days, disappears, to reappear at a later period. The carphologia, 
subsultus, and chewing motion of the under jaw generally occur only a few 
days before death, and lasts but a few days. 

The decubitus, in the early part of the second stage, is generally lateral, 
with the thighs flexed upon the pelvis, the legs upon the thighs, the arms 
applied against the thorax, the elbows bent, and the hands placed in front, 
the decubitus called by the French " en chien de fusil,'' or gun-hammer. At 
this time the child will still occasionally move its position with facility, 
showing that strength is not by any means entirely lost. At a still later 
period the decubitus is dorsal. In the latter part of the first and early 
part of the second stage, the pulse, which we have ascertained to be ac- 
celerated at the invasion, falls to the natural standard, or becomes slow, 
and at the same time irregular. From 110 or 120, as it was, it now sinks 
to 90, 80, 60, or, as happened in one instance to M. Guersant, to 48 in the 
minute. Coincidently with this change it almost always becomes irregular. 
The irregularity affects both its force and frequency, so that a strong pulsa- 
tion may be followed by a feeble one, or the rhythm may be regularly or 
irregularly intermittent. The irregularity varies greatly at different pe- 
riods of the day, or within short spaces of time, so that the pulse is found to 
be very slow at one moment and much more frequent the next. On this 
account it is necessary to examine it on different occasions. Slowness and 
irregularity of the circulation are important as a means of diagnosis, since 
it has very rarely been met with as a permanent condition, except in the 
tuberculo-inflammatory affections of the brain and its appendages. To- 
wards the termination of the disease, generally speaking two or three days 
before death, the pulse rises again in frequency, so that it counts at first 
112 or 120, and gradually increases to 140, 160, or even 200 the day be- 
fore, or that on which death takes place. Simultaneously with this change 
it also becomes extremely feeble and small, and often ceases to be percep- 
tible at the wrist on the last day. 

The respiratory movements also show marked irregularities. During the 
early stage of the disease they are frequent, though we think rarely so 
much so as to preserve the normal ratio to the pulse. But during the 
stage we are now considering, the breathing becomes unequal and irregu- 
lar, and deep sighing respirations alternate with quick superficial ones. 
We have called attention lately^ to a very peculiar modification of respira- 

1 Remarks on Cheyne-Stokes Respiration, especially in connection with tuber- 
cular meningitis, by William Pepper, Phila. Med. Times, May 27th, 1876. 



I 



DIAGNOSIS. 487 

tion, which has been frequently observed by ourselves and others in the 
exudative stage of tubercular meningitis. The following description may 
serve to give an idea of its general character : " The breathing is from time 
to time interrupted by periods of apncea of varying length (five to thirty 
secondsX between which occur a series of respiratory acts, which begin by 
very feeble and barely perceptible movements, and gradually grow fuller and 
stronger until they reach a climax, when they occasionally end by a long- 
drawn sigh, or more commonly, pass through a descending scale of move- 
ments, each growing more and more feeble until they end with barely per- 
ceptible respirations, such as marked the beginning of the series. This 
period of respiration, which also occupies from five to thirty seconds, is 
followed by a second period of complete apna?a, which is in turn succeeded 
by a group of respirations similar to the first." {loc. cit.) This disturbance 
of respiration, together with the interference with the heart's action, depend 
upon the pressure of the exudation upon the pneumogastric nerves; and, 
as they are not found in the affections which may simulate tubercular 
meningitis, must be regarded as possessing considerable diagnostic value. 

The heat of skin, which has fallen with the reduction in the frequency of 
the pulse, generally increases with its acceleration. This is not invariable, 
howes'er, since in some cases the temperature remains but moderately ele- 
vated, about 101° or 102^, until death ; and in others an algid condition 
precedes death, in which the temperature falls as low as 79.4°. {Reynolds's 
Syst. of Medicine, vol. ii, p. 379, art. Tuberc. Meningitis.) On the other 
hand, in some cases the temperature increases irregularly as the fatal re- 
sult approaches, and may attain an extreme height. Thus Roger (op. cit., 
p. 323) has observed on the day of death in an attack of tubercular men- 
ingitis, a temperature of 108.5° F. During the last few days the surface 
is often covered with an abundant perspiration; the tongue becomes dry; 
the teeth and gums are fuliginous; the exhaustion increases; the respira- 
tion becomes stertorous, unequal, difficult, and anxious, and at the very 
last attended with groat dyspncea ; and the urine and stools are discharged 
involuntarily. Death finally occurs in this condition, or is hastened by an 
attack of convulsions. In some cases it is most lingering. In one instance 
we expected the death of a young child in this disease every day for eight 
in succession. 

The duration of tubercular meningitis is exceedingly variable in different 
cases. As a general rule it lasts between eleven and twenty days, though 
it may continue a considerably longer time. Riliiet and Barthez have 
never known death to occur before the seventh day. 

Di.\GNr>tis. — The diseases with which tuberculosis of the meninges is 
most likely to be confounded are simple meningitis and typhoid fever. It 
might also be confounded, though this is much less probable, with the 
cerebral symptoms which complicate the exanthemata and some local dis- 
eases, especially pneumonia, and to which symptoms, as a group, M. Bar- 
rier has applied the term pseudo-meningitis. 

The diagnosis between tubercular and simple meningitis will be best 
understfX)d from the following synoptical table, ba^ed upon the one con- 
tained in the last edition of the work of MM. Killiet and Barthez. 



488 



TUBERCULAR MENINGITIS. 



SIMPLE ACUTE MENINGITIS. 

I. The subjects of acute simple menin- 
gitis are usually robust and well-devel- 
oped, and present no trace of either in- 
ternal or external tubercular disease. 
Born of healthy parents. 



II. The disease may prevail epidemi- 
cally. 

III. Condition prior to invasion. — The 
disease begins in the midst of the most 
blooming health, or, if secondary, it oc- 
curs in the course of, or during the con- 
valescence from, some acute non- tubercu- 
lar disease, or it follows an external cause. 

lY. Mode of invasion. — Violent con- 
vulsions attended with intense febrile 
movement, and with very hurried respi- 
ration in young infants; or very acute 
frontal headache, accompanied by fever, 
bilious vomiting, and towards the end of 
the first, or in the course of the second 
day, at the latest, excessive restlessness, 
preceded or not by somnolence ; most 
violent delirium ; formidable ataxia. 



Y. Symptoms. — Very intense headache, 
ofts^ma^e vomiting, morfera^e constipation, 
violent fever, high delirium. 



YI. From the beginning, the aspect 
of a grave disease of ataxic form. 

YII. Course rapid, aggravation pro- 
gressive and continuous; convulsion after 
convulsion, or else violent delirium, ex- 
treme agitation, violent fever, etc. 

Duration. — Disease of short duration, 
ending sometimes in 24 or 36 hours, but 
lasting generally from three to six days, 
and seldom more. 



REGULAR TUBERCULAR MENINGITIS. 

I. Subjects of tubercular meningitis 
delicate, puny, exhibiting often precoci- 
ous intelligence and sensibility. Have 
sometimes had, in infancy, enlarged 
glands or chronic cutaneous eruptions ; 
the parents, or brothers and sisters, often 
present the signs of tubercular disease. 

II. Disease always sporadic. 

III. Condition prior to invasion. — For 
some months or weeks the patients grow 
languid, lose their strength, become pale, 
emaciate; their temper changes, they 
are dull, they lose appetite, the digestion 
is deranged, etc. Absence of prodromie 
symptoms is rare. 

lY. Mode of invasio7i. — Never with 
convulsions at the onset ; the change 
from the prodromie to the acute stage 
sometimes imperceptible. It takes place 
by a progressive increase of the symptoms 
before mentioned, and by the setting in 
of headache ; in other cases, the acute 
stage is better marked by headache, 
vomiting, and constipation ; generally, 
the intelligence remains clear ; no ataxia. 
In the rare cases in which there is ataxia 
at the onset of the acute symptoms, the 
prodromie stage, above described, has 
been observable, or the meningitis has 
occurred in the course of advanced phthis- 
is. In cases in which no prodromes 
exist, the meningitis begins with vomit- 
ing, constipation, moderate headache, 
and slight febrile movement ; ataxia, if 
it is to appear, occurs later, and a mis- 
take is impossible. 

Y. Symptoms. — 'N ot very intense head- 
ache, vomiting less frequent, very obsti- 
nate constipation, very moderate fever, 
slowness and irregularity of the pulse, 
delirium usually mild. 

V I. Invasion insidious, with the aspect 
of a mild disease. 

YII. Course slow, preservation of the 
intelligence to an advanced period, fever 
slight, and some slowness and irregularity 
of the pulse, sighing, changing color of 
the face, eye dull or ecstatic, etc. 

Duration. — Always much longer in the 
regular form. 



DIAGNOSIS. 489 

We will remark in regard to this table, which is, in most respects, admir- 
able, that we have never met with more intense and persistent headache 
than we have in some cases of the disease nnder consideration. In some 
of our cases this has been a most prominent and striking symptom. 

Before quitting the subject of the diagnosis of these two affections, it is 
desirable to state for the information of the reader, that some of the high- 
est authorities acknowledge it to be sometimes nearly or quite impossible 
to distinguish between them. This is the expressed opinion of ]\IM. Guer- 
sant, Rufz, Barrier, and Valleix. 

From typhoid fever, tubercular meningitis is to be distinguished by the 
antecedent history of the patient, which often reveals the existence of a 
tubercular diathesis in the latter affection ; by the symptoms of the inva- 
sion, which in meningitis consist of severe and persistent headache, frequent 
vomiting, and constipation, whilst in typhoid fever the headache is less 
severe and less persistent, the vomiting much less frequent, and the consti- 
pation replaced by diarrhoea, or at least by an unusual susceptibility to 
the action of laxatives ; by the diflfereut characters of the febrile move- 
ment, which, in typhoid fever, is more marked, and attended with a fre- 
quent, full, and regular pulse, while in meningitis it is less marked and is 
accompanied after a few days by slowness and irregularity of the pulse, 
and by irregularity of respiration ; lastly, in meningitis, the constipation 
is usually marked, the abdomen is retracted, and there are various impor- 
tant and characteristic lesions of motility, and the special senses ; in ty- 
phoid fever there is diarrhoea, the abdomen is distended and meteoric, there 
are characteristic rose-colored spots, whilst there are no considerable lesions, 
either of motility, or of the special senses. Much assistance in the diag- 
nosis can also be obtained by a careful study of the course and changes of 
the temperature in the two diseases. In tubercular meningitis, instead of 
the gradual progress in development, with moderate evening exacerbations, 
which is so characteristic of typhoid fever, the temperature presents great 
and irregular variations; it is specially marked by a period of reduction, 
even to 97° or 96^ (Roger), corresponding to the middle stage, and then 
by a final rise, which may continue increasing until the last day of life, or 
may be replaced by an algid state, with great lowering of the heat of the 
.surface. In doubtful cases, the use of the ophthalmoscope will often be of 
great value. We have already mentioned the retinal changes which are 
frequently seen in tubercular meningitis, whilst in typhoid fever no lesions 
will be detected. 

Although the above general remarks apply to the majority of cases, it 
must not be imagined, however, that the diagnosis between the two affec- 
tions is always ea«y or even possible in the early stages. This is largely 
due to the fact that the typhoid fever of children presents as many irregu- 
larities and departures from the typical course which it more frequently 
follows in the adult. Thus it is not very rare to have epistaxis, diarrh(i*a, 
and even the peculiar eruption ab.sent in typhoid fever in young children, 
and if, when this occurs, the tache clribrale be developed by drawing the 
nail over the skin, it is evident that it will be difficult to decide whether the 
irregular fever, with cerebral disturbance, be the result of the one or the 



490 TUBERCULAR MENINGITIS. 

other of these affections. The symptoms of most value in such obscure 
cases, are irregularity and slowing of the pulse, with unequal and irregu- 
lar respirations ; and strabismus, diplopia, or changes in the optic nerves 
or retina. When these appear, as they usually do in the second stage of 
tubercular meningitis, the diagnosis can scarcely possess any further diffi- 
culty. 

It is unnecessary to do more than allude to the possibility of confound- 
ing the disease with the exanthemata, or with local diseases accompanied 
by cerebral symptoms, and particularly with pneumonia in very young 
children. The resemblance of pneumonia of the apex of the lung in the 
early stage to tubercular meningitis, has been referred to in the article on 
pneumonia. The diagnosis must be made by careful consideration of the 
symptoms peculiar to each, and in the case of a local disease, by accurate 
physical examination of all the important organs of the body. 

Occasionally, also, cases are met with where, in connection with gastro-- 
hepatic disturbance, there is probably some cerebral congestion, and which 
may simulate the early stage of tubercular meningitis. For instance, we 
were called to see a boy eight years old who had been suffering for two 
weeks with violent frontal headache, frequent vomiting, constipation, slight 
fever, and somnolence. We feared that the case might prove to be one of 
tubercular meningitis. However, a large dose of calomel, follow^ed by 
castor oil and free leeching to the temples, relieved him in two days per- 
fectly, and he has remained well ever since, though this was a number of 
years ago. 

Prognosis. — M. Barrier, in speaking of the prognosis of this affection, 
says : " The gravity of tubercular meningitis is not surpassed by that of 
any other disease. Thoracic and abdominal phthisis, though almost con- 
stantly fatal, pursue a slower course, and last a longer time. We may 
even allow as proved, that in a small number of cases, they are suscepti- 
ble of cure, or may remain stationary for months or years. Unfortunately 
it is not so in regard to tubercular meningitis." MM. Rilliet and Barthez, 
in their second edition, do not express the same entire hopelessness as to 
recovery from the disease, that they did in their first. They say, amongst 
other conclusions (op. cit., t. iii, p. 510), that there are on record incon- 
testable examples of the complete disappearance of the symptoms, but 
remark, that such cures have occurred in the first stage, or in the first half 
of the second stage, after seven or eight days of sickness, rarely later, and 
after alternations of amelioration and aggravation. They state also that, 
in excessively rare instances, a return to health has been obtained even in 
the course of the third stage, after many weeks of illness. They are of 
opinion that the disease often returns and proves fatal in from one to five 
years and a half after the recovery. The cause of the relapse is to be 
found in the fact that the local lesion remains, and that the diathesis has 
not been eradicated. M. Valleix is of opinion that after having acquired 
the conviction that a case is really one of tuberculosis of the meninges, 
we should regard the patient as lost; "for the exception that I have men- 
tioned (a case belonging to M. Billiet, then unpublished), even did no 
doubt as to the exactness of the diagnosis remain, ought not, standing by 



t 



PROGNOSIS. 491 

itself, to impart to us auy real security." M. Guersaut (Did. de Med. t. 
xix, p. 403\ seems to think it possible that the disease may sometimes ter- 
minate tavorably in the very early stage, but adds that " such cases are 
always more or less doubtful, and seem to us to belong rather, for the most 
part, to simple meningitis." During the second period (^that of slowness 
and irregularity of the pulse\ he has scarcely seen one child in a hundred 
survive, and even then they perished at a later period of the disease, or of 
phthisis pulmoualis. Of those arrived at the third stage (^marked by re- 
newed frequency of the pulse, coma, and lesions of motility and sensibility), 
he has never seen any recovery, even momentarily. Dr. George B. Wood 
(Prac. of Med., vol. ii, p. 365), states that he has " never seen a well-marked 
case of tuberculous meningitis end favorably." Dr. Robert Whytt ( Works 
of JRobcrt Whytt, published by his son, quarto, Edinburgh, 1768, p. 745), says : 
" I freely own, that I have never been so lucky as to cure one patient who 
had those symptoms which with certainty denote this disease ; and I suspect 
that those who imagine they have been more successful have mistaken 
another distemper for this." 

In the quarterly abstract furnished by Dr. A. Wiltshire in the Brit, and 
Foreign Med.-Chir. Bev., for April, 1876, at page 465, it is stated that Dr. 
Clifford Allbut has known of two cases of recovery from tubercular men- 
ingitis, in which the diagnosis made with the aid of the ophthalmoscope 
was verified some years later at the autopsies of the patients. And at the 
same place is quoted another case by Dr. Rinteln (Berl. Klin. Wochnschr., 
No. 21, 1876, p. 287), where recovery occurred after all the recognized 
symptoms of tubercular meningitis had been present, and where this diag- 
nosis with a consequent fatal prognosis was made by all the physicians who 
saw the patient. 

Our own experience coincides with the mass of evidence given above as 
to the almost hopeless fatality of the disease. All the undoubted cases 
that we have seen have proved fatal. A case, however, came under our 
observation, in 1850, which might, perhaps, be classed as a recovery from 
tuberculosis of the meninges, though not from tubercular meningitis, 
since there were no well-marked signs of inflammation of the membranes 
of the brain, though there was every reason to suppose that the symptoms 
depended on the deposit of tubercles in those membranes. The case was 
as follows : 

A girl botwcen four and five years old, whoso mother was then hiboring undor 
tubercular disease of the summit of one lung (which has since proved fntnl), and 
who had lost several brothers and sisters with consumption, had had nearly con- 
stant cough during the winter of 1849-50, During the months of April, May, and 
June, of 1850, she had exhibited all the signs of induration over the upper two or 
three inches of the right lung, before and behind, — marked dulness on percussion 
and bronchial respiration, but no rale. For these symptoms she had been treated 
with cod-liver oil, iodide of iron, opium for the coutrh, and good diet. From the 
middle of June she complained frequently of headache, had occasional vomiting 
without any gastric derangement, and was much disposed to be constipated. iSho 
bad no appetite, grew thin, and was very languid, listless, and weak. On the 27th 
of June the mother thought she observed some squinting. On the 2fUh we found 
that the child had lodt all power over the right muscles of the right eye, so that 



492 TUBERCULAR MENINGITIS. 

when she looked towards the right hand, she squinted dreadfully. She was dull and 
heavy, and vomited two or three times a da}'. The pulse was 62 to 75 or 80 ; there 
was a slight hitch in its beat, but no decided intermittence. The child said that she 
sometimes saw two things instead of one From this time until July 7th, she con- 
tinued in much the same state. On the first July, finding that the eyes were quite 
yellow, and that the child was constipated, we ordered half a grain of calomel morn- 
ing and evening. After three doses she was purged. This relieved her a good deal, 
there being less headache, more appetite, and an improvement in color afterwards. 
But still there was ever}' day some vomiting, complaints of headache, and more or 
less listlessness and heaviness in the morning, while in the afternoon she would 
brighten up and seem better. The intelligence continued perfect ; the temper was 
rather irritable, but not very much so. 

The treatment after the 29th of June was calomel, given as above stated, from 
time to time, to keep the bowels soluble; cod-liver oil, a teaspoonful twice or three 
times a day, as the child would take it; mustard foot-baths ever}' day or two ; and 
meat, bread, and ice cream for diet. On the 5th July we ordered half a grain of 
iodide of potassium, three times a day, in addition to the oil. 

On the 11th Jul}', she was taken, by our direction, to the seaside, where the use 
of the oil and of the iodide of potassium was to be continued. 

On the 7th of August she was brought back from the seaside, and we saw her on 
the 8th. We were astonished to see how well she looked. The strabismus had en- 
tirely disappeared. We were told that it had begun to diminish two weeks after 
her arrival at the sea, and had then gradually disappeared. She had grown some- 
what, though not very much, fatter. Her whole appearance was very much im- 
proved. The coloration of the body, the expression of the face, were both much 
better; she was much stronger, running about, in fact, all day ; she ate well, and 
with the exception of a little cough, and a rather delicate frame, looked very well. 
Except one day, she was well all the time at the seashore. On that day she was 
feverish, had much headache and vomiting, and laid abed. The cod-liver oil and 
iodide of potassium were ordered to be continued. 

The child remained pretty well throughout the winter of 1850-51. There was no 
return of either the strabismus or the vomiting. She was thin, pale and delicate- 
looking, coughed occasionally, and the solidification of the summit of the lung con- 
tinued, but she was not confined to the house. Late in the winter she went south 
with her mother, and there, after having become quite stout and healthy during 
their travels, died of dysentery in April or May. The mother died in 1852, of 
phthisis, with large cavities in both lungs. 

Another case, in which the early symptoms of the disease were well 
marked, and in which recovery took place, will be detailed in the remarks 
on prophylactic treatment. 

In the following case, also, the diagnosis was of tubercular meningitis 
in the early stage : 

The patient was a boy eight years of age, whose father had died a few years be- 
fore of phthisis, the younger brother died of tuberculous meningitis, and the sister 
of hooping-cough, with the lungs filled with miliary tubercles, as ascertained by a 
post-mortem examination. The child, after having had fair health previously, 
was seized, towards the end of March, 1865, with frontal headache, very slight 
fever, occasional vomiting, constipation, hesitating pulse, languor, willingness to 
lie abed, and a tendency to somnolence. He was treated with rest, milk and beef 
tea in alternate doses, and mustard foot-baths morning and evening ; the bowels 
were kept moderately open, and he took tincture of the chloride of iron in combi- 
nation with dilute acetic acid and solution of the acetate of ammonia every three 



PROGNOSIS. 493 

hours. Under this treatment he improved, and in ten days had quite recovered. 
His mother removed from this city to Washington, where he died on the 30th of 
June of the same year, after an illness of twenty-one days, of what was called 
water on the brain. 

In another ca^e to which one of us was called in consultation, a boy 
whose mother had died a few years before of diabetes mellitus, and whose 
father's family was tuberculous, presented a series of symptoms which we 
could explain only as the result of slow thickening of the membranes at 
the base of the brain, in all probability the result of a tubercular deposit. 
This child had, for several weeks, violent frontal headache, constipation, 
loss of flesh, lassitude, a peculiar one-sided or lateral gait in walking, 
strabismus, and great impairment of vision, so that he could see a small ob- 
ject only by bringing it almost in contact with the face. There was scarcely 
any disturbance of the circulation, and only slight febrile heat at night. 
He was treated at first with rest, nutritious food, minute doses of bichloride 
of mercury in combination with iodide of potassium, three times a day, and 
then when he began to improve, with tincture of the chloride of iron and 
cod-liver oil for a long period. He finally recovered his health, grew 
stout and strong, but has remained ever since so blind that he reads with 
great difficulty, but manages to pick his way through a room or the street, 
with only occasional stumbling. The illness occurred several yeai-s ago, 
and he is still living in good general health at this time. 

Are we then to abandon all hope of deriving any good from medical 
means in the disease under consideration ? To this most serious question 
we ought clearly to respond in the negative. The grounds for entertaining 
hope are first, the evidence of M. Guersant that he has seen cases which 
appeared to be tubercular meningitis recover in the first stage. Let it be 
supposed, even, that they were cases of simple inflammation. But they 
were undistinguishable from the tubercular disease by one of the most 
celebrated of modern physicians. Surely, therefore, it may happen to men 
of inferior skill to meet with the same difficulty, or if we may so speak, to 
make the same mistake, if a mistake was made. It is said by M. Valleix 
that M. Rufz, after determining at the autopsy, that a case which he had 
witnessed was one of simple meningitis, asserted that it would have been 
impossible to distinguish it from the tubercular disease during life. Again, 
M. Rilliet has, according to M. Valleix, seen one case of recovery from 
what he believed to be the tubercular affection, and MM. Rilliet and 
Barthez, in their second edition, a.s above quoted, a.«sert its occasional cura- 
bility. To these authorities must be added the valuable evidence of Dr. 
CliffVjrd Allbutt, already quoted ; and it would be possible to cite still 
further instances, if it were necessary. We know of the occurrence of a 
case in this city, under the charge of one of our friends, than whom we be- 
lieve no one can be more competent to make a correct diagnosis, in which, 
after the child had presented in regular order all the early symptoms of 
the di.*ease, and had arrived at the last and most hopeless stage, f)erfect 
recovery, to his utter amazement, gradually took place. This child, when 
our friend last heard of it, three months afterwards, was in all respects 
stroDg and hearty. No doubt the probabilities are that the case was one 



494 TUBERCULAR MENINGITIS. 

of simple meningitis, but who could have known this at the time ; and 
should it not deter us from abandoning all hope, and, as a consequence, all 
active treatment, when we seem to have under our hands a case of this 
dreadful malady? Our own cases, given above, also go to prove that the 
disease is sometimes curable in its early stages. 

It is important, in tubercular meningitis, to avoid making a positive 
prognosis as to the period at which death will occur, notwithstanding that 
the patient may present every mark of an immediately fatal termination. 
We have already adverted slightly to this subject. On one occasion we 
expected the death of a patient with this malady for three days in succes- 
sion, and on another, we visited a child for a week, during every day of 
which it seemed as though existence could not endure until the next. It 
had during this time profound coma, subsultus tendinum, and enlarged 
pupils; the eyelids were half open, the eyes constantly oscillating, or else 
rigidly distorted, and both corneas dimmed and slightly eroded, from con- 
stant exposure to air and light. Convulsions occurred from time to time, 
the pulse w^as variable, and at times exceedingly frequent, and indeed 
everything threatened a speedy termination. MM. Killiet and Barthez 
say, " Often have we inscribed upon our notes death imminent, and been 
astonished the next day to find still alive, children to whom we had 
allowed scarcely two hours of life." 

The symptoms which most positively indicate the near approach of 
death are, livid color of the face, sweats occurring about the face, glassy 
expression of the eye, dry and incrusted nostrils, and especially a very 
rapid pulse, and the various nervous symptoms mentioned, as carphologia, 
subsultus tendinum, and general convulsions. 

Treatment. — In the early editions of this work we took the ground 
that it was proper in the early stage of the disease to employ bloodletting. 
Further experience and knowledge compel us to retract this opinion. 
We believe now^, that abstraction of blood should not be resorted to unless 
when the diagnosis between this disease and simple meningitis is very un- 
certain. Where there are no marked signs of active inflammation, where, 
from the family history, from the absence of marked fever, and the peculiar 
state of the pulse, we have every reason to believe that the low-typed in- 
flammation present is the result of the presence of tubercle, we deem it 
safest to avoid all lowering measures. The case is so critical, so almost 
hopeless from its very nature, that we prefer a treatment based on the 
theory of promoting a retrogression of the tuberculous deposit. The only 
measures which, in an experience of over thirty years, we have found to 
delay and, in the cases referred to in the article on prognosis, to cure the 
disease in part, have been the following : quiet of body and mind, obtained 
by means of rest in or on the bed, in a pleasant room, with attendants who 
know how to soothe and still the child. We always insist upon a nutri- 
tious diet: and one consisting mainly of milk and cream, or the two mixed, 
with beef tea, bread and butter, if the patient will take it, or milk- 
toast, in moderate quantities every three or four hours, a soft-boiled egg, 
or the yelk of a hard-boiled egg, once or twice a day, is what we usually 
endeavor to get the patient to take. A mustard foot-bath two or three 



II 



TREATMENT. 495 

times a dav, is always safe, and we think useful and tranquillizing. The 
bowels should be moved gently once a day, or every two days, by means 
of an enema or some sim})le laxative, as simple syrup of rhubarb. Active 
purgation we have found of no use. As remedies, we prefer the following : 

R.— Tr. Forri Chlorid., f^j. 

Acid. Acot. Dil., f^j. 

Liq. Amnion. Acetat., ..... t^ij. 

Syrup. Simp., . . . . . , . f^}. 

Aqua?, ^S'jss. — M. 

A teaspoonful at five years of age. every three or four hours. 

In connection with this, we give half a teaspoonful of cod-liver oil in 
emulsion three times a day. Calomel we have abandoned of late years 
entirely, as it has utterly failed in our hands to do any good. 

Iodine has been very much employed as a remedy in this disease, both 
in the forms of Lugol's solution and iodide of potassium. Perhaps the 
strongest argument which exists in its favor is the benefit which often fol- 
lows its employment in other scrofulous and tuberculous diseases; though 
there are several cases in which it is asserted to have been successfully 
u.sed in tubercular meningitis. Iodine itself is comparatively little used. 
M. Rilliet {op. cit., t. iii, p. 308, 1847) states that it has entirely failed in 
his hands in the tubercular form of the disease; the only influence which 
it seemed to exert was to cause the immediate suspension of the coma. 
This was its efl^ect also in a case in which we employed it, that of a girl 
seven years old, to whom we gave two drops of Lugol's solution three 
times a day, from the thirteenth to the twentieth day, when she died. 
The day before her death she seemed to improve somewhat, and we were 
in hopes that it had been of some service. The amelioration did not con- 
tinue, however, and we are now disposed to believe that the change was 
one of those which often take place naturally in the disease. 

Iodide of potassium was recommended more than twenty years ago by 
Roeser {HufelatuVs Journal, April, 1840), as a remedy of special power 
in this disea.se. It has since then been very widely employed, and there 
are quite a number of cases in which it is asserted that its administration 
ha.s been followed by successful results. 

Dr. 'WesKop.cit., 4th Amer. ed., p. 97) thinks that he has seen good 
from its employment, "and that in one instance of what seemed to be ad- 
vanced tubercular liydrocephalus, under the care of my friend and former 
colleague, Dr. Jenner, recovery took place under its employment." 

Niemeyer (op. cit., vol. ii, p. 218 j speaks as follows of its use : "On the 
strength of two successful cases, opposed, it is true, by a large number of 
unsuccessful ones, I recommend large doses of iodide of potassium, con- 
tinuod for a long time." 

Dr. J. Lewis Smith (op. rit, p. 145; al.«o recommends its use through- 
out the entire disease, beginning as early as possible in the premonitory 
period. 

Successful cases of its administratioD are also reported by Drs. Bourrose 



496 TUBERCULAR MENINGITIS. 

de Lafore, Coldstream {Edin. Med. Jour., Dec. 1859), and Carson (Med. 
Times and Gaz., March 5th, 1857). 

We have ourselves frequently administered it, either alone or in combi- 
nation with small doses of bichloride of mercury, but have not yet been 
fortunate enough to arrest the progress of any case when once the second 
stage has been fully developed. In a few cases, however, the use of the 
following combination : 

R. — Potass. lodidi, ^j. 

Hydrarg. Chloridi Corrosivi, gr. j. 

Syr. Simp., f^j. 

Aqu8e, f^^i'j- 

Ft. sol. Dose, a teaspoonful three times a day at five years of age, 

has seemed to delay the march of the disease, in one some weeks, and in 
another, the one already mentioned, it seemed to have a positive effect in 
promoting the absorption of the exudation upon the membranes at the base 
of the brain. It is improbable, also, that in all of the reported cases, errors 
of diagnosis were made, and simple meningitis taken for the tubercular 
form ; so that there is no remedy from which so much benefit may be hoped 
for in this almost hopeless disease, as iodide of potassium in full doses, and 
it should tlierefore be faithfully tried whenever opportunity offers. We 
have been in the habit of giving it in doses of one or two grains every three 
or four hours, to children two years of age. It has, however, been given 
to the extent of a drachm in the course of a single day to children of that 
age. It ought to be begun with early in the case, and continued in con- 
nection with counter-irritation and cold to the head. We must remark, 
however, that it sometimes irritates the bowels too much, causing diar- 
rhoea ; and here the dose ought to be greatly reduced, or the remedy with- 
drawn. 

Bromide of Potassium, on account of its undoubted power in cases of 
active cerebral congestion with great nervous excitement, may be advan- 
tageously associated with the iodide, and we are in the habit of combining 
from three to five grains of the former with the dose of the latter above 
recommended. 

The treatment which has just been described is that which we have 
been led by our convictions as to the nature of the disease, and by our 
personal experience of different plans, to adopt as the most reasonable and 
the best. It is proper to state, however, that we have never seen it, nor 
any other method, of any avail after the disease has passed into the latter 
part of the second stage — when coma, dilatation of the pupils, marked 
strabismus, paralytic or convulsive phenomena, show the presence of in- 
flammatory exudation under the membranes, and of serous effusion into 
the lateral ventricles, or the peculiar lesions of the substance of the brain 
which exist at that period of the malady. It is also proper to add that 
other means have been recommended by high authorities, and to these we 
shall now devote some remarks. 

Counter-irritation in different forms has been employed, and apparently 
with success, though it has failed in our hands. Blisters to the nucha, be- 




TREATMENT. 497 

hiud the ears, or over the whok^ scalp, liave been used. At one time, in 
this citv, it was a comniou practice to cover the scalp with a blister, but it 
was found to fail so constantly, and was so j-wiinful a sight to the relations 
of the child, that it has been very much abandoned. Surely, if it had 
succeeded in any considerable proportion of the cases, it would have been 
received as a boon, however revolting to the sight. We have, ourselves, 
in past vears, blistered the nucha, the back of the ears, and the temples 
in a number of Ciises, but have always failed to obtain any evident good 
from them. Within a few years it has been claimed that pustulating the 
whole sinciput with croton oil has been of great service. The last case of 
tuberculous meningitis we saw, occurred in an adult, and here we had 
nearly the whole of the crown of the head shaved, and pustulated with the 
oil, but it was of no use whatever. 

Cold applications to the head have been very much used. We have 
employed them ourselves, and still use them whenever the head is hot, or 
when their use relieves the headache or soothes the patient, but we confess 
that they have not seemed to us of much use except as palliatives. They 
may consist of cloths wet with cold water, of affusions with cold water, or, 
as has been proposed by M. Guersant, of irrigation as employed in sur- 
gery. M. Guersant prefers this mode of applying cold to any other, be- 
lieving it to be the most convenient and comfortable to the child, and 
from its continuous action, the most efficacious. To make use of it, the 
hair is to be shaved or closely cut, and the child placed upon a mattress 
without a pillow, and with its head near the edge of the bed. The head 
is then covered with compresses of soft rag, or, better still, of patent lint, 
while under it is placed a piece of oiled silk or india-rubber cloth, so ar- 

nged as to keep the thorax from being wet, and doubled into a gutter 

ve to convey the water off into a vessel placed on the floor. A bucket 

r basin filled with fresh, cool water, is placed near the head of the bed, 

d from this a siphon made of lint or lamp-wick is so arranged as to 
convey a stream of water upon the compresses covering the head. If the 
heat of the whole body falls so much as to threaten collapse after the irri- 
gation has been continued for some time, the stream of water should be 
stopped, and compresses, merely wet with water not quite so cool, kept on 
the head. The latter precaution is necessary in order to prevent injurious 
reaction from the sudden and total removal of so powerful a sedative as 
irrigation proves to be. 

Some practitioDers prefer the use of ice in a bladder. This seems, how- 
ever, too severe a remedy to be long continued, and we should therefore 
rather use only cloths wet with iced-water, or irrigation. Dr. Abercrombie 
is of opinion that the application of cold is by far the most powerful local 
remedy that we have. M. Gendrin recommends cool or cold affusions 
over the whole surface, the temperature to be proportioned to the heat of 
the skin. When there is but little heat of head, only a slight febrile 
movement, and the headache is not relieved by cold applications, ( Juer- 
saot recoromeDds the substitution of warm poultices to the scalp, in the 
place of irrigation or cold applications. 

We have already stated that calomel has not succeeded in our hands, so 

32 



498 TUBERCULAR MENINGITIS. 

that we have abandoned its use We deem it right, however, to lay be- 
fore the reader the opinions of others upon this point. Thus, it is highly 
recommended by many of the English writers on acute hydrocephalus, 
and is asserted to have effected cures when it has been pushed to such an 
extent as to produce salivation. But little dependence, however, can be 
placed on these assertions, as in all probability the reported recoveries oc- 
curred in cases of simple meningitis. The French writers speak of hav- 
ing used it in very large quantities without any success. It was given to 
many of the patients of MM. Killiet and Barthez, in the quantity of from 
six to ten, increased to twenty grains, in twenty-four hours, in connection 
with frictions with mercurial ointment, of which two drachms and a half 
were used at first, and the quantity afterwards doubled and trebled. They 
state that salivation did not occur in any of the cases, though fetor of the 
breath and inflammation of the gums were of frequent occurrence. Cal- 
omel may be given, as has been remarked, in purgative doses, at the be- 
ginning, and for the purpose of procuring its specific, effects. With the 
latter view the dose may be from a quarter of a grain to a grain, every 
hour or two hours. Mercurial inunction, in conjunction with the internal 
administration of the remedy, has been highly recommended by several 
writers as an efiicient means of procuring the full effect of the drug upon 
the constitution. About a drachm of the ointment is to be rubbed into the 
insides of the arms and thighs morning and evening, and the quantity 
gradually increased if no effect is produced. For our part, we will merely 
state that we have never known calomel given in large quantities, in order 
to procure salivation, of the least benefit in the disease. On the contrary, 
we cannot but think that the violent irritation of the digestive mucous 
membrane which it has determined, whenever we have used it largely, 
and the inflamed, irritated condition of the mouth which it caused in one 
case, must have been a serious aggravation of the state of disease under 
which the constitution was laboring. Mercury is well known to be an in- 
jurious and dangerous remedy in the tubercular diseases of adults, having 
for its effect to increase the dyscrasia of the constitution, which already 
exists, and thereby to hasten the progress of the malady. Why it should 
have a different effect in children is difficult to understand. It may be 
said, to be sure, that in the disease we are considering, it is given to over- 
come the inflammatory element of the malady, which, for the time, con- 
stitutes the danger of the case, and also to allow the patient the chance of 
its beneficial operation should the disease happen to be one of simple 
meningitis. In support of the views just expressed, we will quote the 
opinion of Dr. John Abercrombie (Diseases of the Brain and Spinal Cord, 
Philad. ed., 1831, pp. 173-6) : "Mercury has been strongly recommended 
in that class of cases which terminates by hydrocephalus, but its reputa- 
tion seems to stand upon very doubtful grounds. In many cases, espe- 
cially during the first or more active stage, the indiscriminate employment 
of mercury must be injurious. ... In the preceding observations, I shall 
perhaps be considered as having attached too little importance to mercury 
in the treatment of this class of diseases, particularly in the treatment of 
hydrocephalus ; but in doing so, I have stated simply what is the result 



TREATMENT. 499 

of an extensive observation, . . . and I confess, the result of my observa- 
tions is, that when mercury is useful in affections of the brain, it is chiefly 
as a purgative." 

It has been recommended, within a few yeai-s, by Sir B. Brodie, to em- 
ploy mercurial inunction as especially applicable in using mercury for 
children. He advises that a drachm or more of the ointment be spread 
upon one end of a flannel roller, which is to be applied, not very tightly, 
around the knee ; repeating the application daily. " The motions of the 
child produce the necessary friction ; and the cuticle being thin, the mer- 
cury easily enters the system." The editors of the journal in which this 
communication is made {Braith. Metrosp. of Med., vol. iv, 1846, p. 147, 
from Quart. Med. Bev., July, 1846, p. 169), state that they tried this plan 
in a case of acute hydrocephalus, in which some of the most urgent and 
fatal symptoms were present, " such as very dilated pupils, constant con- 
vulsions, hemiplegia, and more or less stertorous breathing ; in short, so 
violent were the symptoms, that we considered the case perfectly hopeless ; 
but on reflecting on Sir Benjamin's method, we ordered strong mercurial 
ointment to be smeared on each leg every twelve hours, and covered with 
a stocking made to tie tightly above the knees. The symptoms soon began 
to abate, and by following this up with small doses of iodide of potass., 
frequently repeated (gr. i, every three or four hours), the head symptoms 
vanished. 

" In a second case, the same set of symptoms were approaching, but 
were stopped by the same mode of treatment." 

When the convulsive symptoms are violent and distressing, they may 
often be moderated by the use of a warm bath, which must be carefully 
given, and by the administration of some of the antispasmodics. AVe 
prefer for this purpose the fluid extract of valerian, of which from ten to 
twenty drops may be exhibited every two or three hours to young children, 
and a larger dose to those who are older. Bromide of potassium has also 
been recommended on account of its peculiar sedative action, and M. Bazin 
( Gaz. de Hopitattx, 1865) narrates a case in which large doses of this remedy 
were successful in checking the progress of tubercular meningitis, in a lad 
who presented at the same time the symptoms of pulmonary tuberculosis. 

As a general rule, narcotics of all kinds are to be avoided, from their 
effect of increasing the constipatioD, and exciting more or less the cerebral 
circulation. When, however, neither antiphlogistics, evacuants, nor cold 
or warm applications relieve the sufferings of the child, it would be proper 
to employ small laudanum poultices or opium plasters upon the forehead 
or temples, or we may use morphia by the eudermic method. 

The treatment described in the preceding pages, is that which is proper 
for cases of the disea.«e occurring in subjects previously in good health, or 
evincing but few signs of the tubercular cachexia. When, on the con- 
trary, it occurs in children with extensive tubercular afl^ections of other 
organs, by which they are already weakened and exhausted, the treatment 
must of course be modified to meet the circumstances of the case. It 
ought to consist chiefly of cold applications, and of an early use of cod- 
liver oil, of iodine, or of the iodide of iron. We should recollect that 



500 TUBERCULAR MENINaiTIS. 

experience has long since shown the weakness of our art in such cases, and 
for that reason avoid such a degree of interference as might possibly 
abridge the little span of life allowed the patient by this relentless malady. 
Prophylactic Treatment. — It must be evident that the prophylactic 
treatment is of especial importance in a disease so little amenable to 
curative means as the one under consideration. When, therefore, there is 
reason to suspect a tendency to tubercular meningitis in a child, either 
from the fact that other children in the family have perished with it, or 
from a bad state of the general health, and frequent complaints of head- 
ache, it becomes proper and necessary to regulate both the moral and 
physical education with a view to its prevention. For this end the hygienic 
management of the child ought to be such as is best calculated to prevent 
the formation or development of tubercles in the constitution. During 
infancy, such a child should be nursed, if this be possible, by a strong, 
hearty woman, with an abundant flow of milk. If the mother is not 
possessed of these qualities, if there be, indeed, the least doubt upon the 
point, she ought without hesitation to give up the pleasure of nursing the 
child herself, and procure for it a wet-nurse of the kind described. This 
alone will, in all probability, often make a difference between a vigorous 
and a fragile constitution. When the time for weaning arrives, the change 
ought to be made with the greatest care and circumspection. During and 
for some time after weaning, the diet must consist principally of milk 
preparations and bread, and of small quantities of light broths, or of 
meat very finely cut up. As the child grows older, the meals ought to be 
arranged at regular hours, and should consist of four in the day. The 
principal food must be bread and milk, well-chosen, well-cooked meats, 
and rice and potatoes as almost the only vegetables. After the first den- 
tition is completed, a moderate use of ripe and wholesome fruits may be 
allowed, but always with care, in order to avoid injury to the digestive 
organs, and also so as not to mar the appetite for more wholesome and 
nutritious food. Coffee and tea ought to be forbidden at all times ; since, 
as we have often observed, when the palate of a child is taught, by habit, 
to become accustomed to these more highly sapid substances, it is very apt 
to abandon the use of milk, which ought to constitute a large proportion 
of its food, at least up to the age of twelve or fifteen years. In no circum- 
stance of life is the old saying, " where ignorance is bliss, 'tis folly to be 
wise," a better rule of action than in regard to the diet of our children. 
The child should not taste improper articles of food, so that it may escape 
the torment of desiring what is improper. 

After diet the most important points in the treatment are air and cloth- 
ing. The child should inhabit, if possible, a large, dry, well-ventilated 
room, which ought to be kept as cool as possible in summer, and moder- 
ately warm in winter. Not a day should be allowed to pass, unless the 
weather is totally unfit, without the child's being sent for several hours 
into the open air, and we believe that it is much better for it to walk than 
drive, unless the weather be very hot. The clothing ought to be suitable 
to the season, cool in summer and warm in winter. In our country there 
is a great inclination to harden children by dressing them very slightly in 



PROPHYLACTIC TREATMENT. 501 

cold weather ; so that they frequently suffer from catarrh, pneumonia, and 
spasmodic croup brought on by improper exposure. This cannot but be 
wrong in a child who shows the least evidence of a tendency to tubercular 
affections. 

For our own part we are fully convinced from what experience we have 
had of the diseases of children, that by far the most certain and effectual 
means of preventing the development of a tubercular, or indeed any other 
cachexia in a child, is to have it brought up in the open country, or in 
some healthy village, until the epoch of puberty has passed by safely. A 
very good plan for parents whose occupations compel them to live in cities 
or large towns, is to have their residence a few miles in the country, and 
to come to town every day. Children brought up in this way have a far 
better chance of obtaining strong and vigorous constitutions, than those 
reared entirely in the close and confined dwellings and streets of crowded 
cities. 

When a child, who, from the health of its parents, or from its own ap- 
pearance, may be suspected of having any tubercular or scrofulous taint 
in its system, becomes subject to frequent attacks of apparently causeless 
headache, and especially when such headaches are associated with a con- 
stipated habit of body and with occasional vomiting, it ought to be looked 
upon as threatened with tubercular disease of the brain. Under these cir- 
cumstances we would advise, in addition to the measures just now recom- 
mended as to diet, dress, exercise in the open air, and a residence in the 
country, that it be put at once upon the use of cod-liver oil, iodide of iron, 
and mild laxatives, and that these be persevered in for several weeks or 
months, until in fact the strength and general health are restored and the 
headaches cease. When the appetite is poor, and the digestion is imper- 
fect, in such a case we may use with advantage, besides the above reme- 
dies, solution of pepsin, a teaspoonful three times a day with the meals, or 
tincture of nux vomica, three or four drops in a mixture of syrup and 
compound tincture of gentian, or in a teaspoonful of elixir of cinchona 
three times a day. If the child is of an age to be going on with its educa- 
tion, this should for the time cease, or be carried on in such a way as to 
avoid all excitement or fatigue. A case occurred to one of us in the 
course of the year 1852, which showed, we think, very clearly the utility 
of these measures. 

A boy between seven and eight years old, whose mother had died of well-marked 
pbthis>i<< a few months before he was put under our charge, had been losing flosh and 
flrength, and suffering from occasional headache for some time before we were called 
to see him. We found him in bed complaining of severe frontal headache ; so 
severe at times, and usually in the afterqiart of the day, as to cause great distress, 
with crying. The intelligence was perfectly natural. The child was rather dull 
and listless, from suffering and from weakness, but not from any want of a health- 
ful stale of the mental of»eralions. There was no sign whatever of spasmodic or 
paralytic affection. In the morning the skin was cool and natural, but in the after- 
noon it became warm and dry, but not very hot. The pulse was 02 to G8, and 
though not actually irregular, it was halting or hesitating. There was occasional, 
but not frequent, unpinivoked vomiting, and he complained often of sick stomach, 
even when be did not vomit. The bowels were very much constipated, and had 



502 TUBERCULAR MENINGITIS. 

been a good deal so for some weeks previous to his falling actually sick. There 
was no cough, no sore throat, and no soreness about the abdomen. The tongue 
was moist, soft, slightly furred, and not red nor gashed. The urinary secretion 
was healthy. Physical examination showed the lungs and heart to be without 
disease. 

The treatment during the first week was small doses of calomel and rhubarb, half 
a grain of the former to two of the latter, given for a day, and followed by syrup 
of rhubarb and fluid extract of senna, until the bowels were copiously evacuated. 
After this the bowels were kept soluble by the administration every day, or every 
other day, of doses of Seltzer powder, sufficient to produce the effect. Blisters were 
applied behind the ears. In the after-part of the day, when the head and body 
became heated, cooling applications were made to the head, and the feet were put 
into mustard-water, once, twice, or three times. Two grains of iodide of potassium 
were ordered to be given three times a day. The diet was to be light but nutri- 
tious. It was to consist of bread and milk and a soft-boiled egg in the morning, 
oysters or light meats with rice for dinner, and milk with bread in the evening. 
Of these he was to have any reasonable quantity that he might desire. Under this 
treatment he improved slowly, with occasional drawbacks for a week, when the 
iodide of iron was substituted for the iodide of potassium. The bowels continued 
very costive, requiring daily doses of the Seltzer pow.dcr ; the headaches dimin- 
ished in frequency, duration, and severity ; the pulse went up to 72 and 78, and 
became more free and even ; the appetite had improved, but the child remained 
still very weak, pallid, and quite emaciated. After another week, as he continued 
to mend, and the stomach had become stronger, cod-liver oil was ordered in addi- 
tion to the iron ; a teaspoonful was to be taken three times a day in a wineglassful 
of table-beer. As he gained strength, the amount and kind of food was increased. 
He was, indeed, encouraged to eat heartily of plain and digestible substances. 

He now improved gradually in health. The headaches subsided, and finally 
ceased ; the bowels became soluble ; the appetite grew hearty and strong, and all 
feeling of nausea disappeared ; he regained his strength, flesh, and color, so that at 
the end of two months we saw him looking quite fat and well. The iodide of iron 
and cod-liver oil were, however, to be continued for a month longer. He is now 
(1869) a young man in very good health. He has passed several years in Germany 
pursuing a scientific education, and has returned lately to this country, and is about 
to marry. 

As to the particular means likely to be of service in preventing a direc- 
tion of the tubercular cachexia towards the brain, such as might produce 
tuberculosis of that organ, we have only to propose the course recommended 
by different writers, viz., to keep the head cool by not allowing it to be 
very warmly covered, and by keeping the hair short ; to keep the extremi- 
ties warm ; to avoid stimulating the intellectual faculties to any consider- 
able extent by education, until after eight or ten years of age ; and to use 
every means to preserve the general health in a sound and pure condition. 
Some recommend the long-continued employment of a powerful derivative 
from the brain, as a small blister on the arm or a seton in the neck. We 
think, however, that such remedies ought not to be used unless there are 
positive symptoms of a tendency to cerebral disorder. The caution not to 
interfere much by powerful local applications, with eruptions which nature 
may have thrown out upon the scalp, is, we believe, wise and prudent ; 
though there can be no objection to the administration of suitable internal 
remedies with a view to their cure. 



I 



SIMPLE MENINGITIS. 503 

ARTICLE II. 

SIMPLE MENINGITIS. 

Definition; Synonyms; Frequency. — By this term is understood in- 
flararaatioii of the niembraues of the braiu, iudependeiit of tuberculosis of 
those tissues, or of other organs of the economy. 

The disease was for a long time confounded with tubercular meningitis 
under the titles of water on the brain, dropsy of the brain, and acute hy- 
drocephalus. It has also been called arachnitis ; and more rarely phrenitis. 

Its frequency is much less than that of tubercular meningitis. West 
(op. cit., 4th Amer. ed., p. 100), states that he has seen seven cases of fatal 
acute meningitis, in five of which post-mortem examination was made and 
confirmed the diagnosis. Vogel i^op. cit., p. 359) speaks of it as being much 
rarer than the tubercular form, and states that it is no more frequent in 
children than in adults. It appears that MM. Rilliet and Barthez, during 
their researches, met with only five cases of this disease, while they report 
thirty-three of tubercular meningitis. Bouchut states that he has met 
with two cases of simple meningitis to six of tubercular disease, whilst 
Barrier reports only four of the former in nearly thirty autopsies of menin- 
gitis. He states, however, that he has met with three cases of recovery, 
all of which he believes to have been instances of the simple form. Fabre 
and Constant met with nine cases of simple to twenty-seven of tubercular 
meningitis in a period of two years, at the Children's Hospital of Paris. 
{Bibliothtque du Med. Prat., t. vi, p. 166.) 

Causes. — The causes of simple meningitis are not very clearly ascer- 
tained. It would appear, however that the disease is more common in 
infants than older children. M. Rilliet. who published a very valuable 
paper on this affection (Arch. Gen. de Med., t. xii, 1846), divides it into 
two forms, the convulsive and phrenitic, the former of which he believes 
to be most common under two, and the latter between five and fifteen 
years of age. This author is disposed to think, from the fact that the dis- 
ease is most frequent in the first and ninth years of life, that the process 
of dentition has something to do in its production. It appears also to be 
more frequent in boys than girls, and in robust than in weak constitutions. 
Exposure to extremes of temperature predisposes to attacks of acute men- 
ingitis; and, in particular, rontinuod exposure to the direct rays of the 
8UD has been known to act as an immediate cause. 

Guersant has known it to follow such exposure in several instances par- 
ticularly in young infants; MM. Rilliet and Barthez report a case of the 
game kind, and Rilliet (he. cit.), another. Other caus&s cited by authors 
are injuries upon the head, such as blows, falls, and wounds. It also 
occurs as a consequence of extension of inflammation to the membranes of 
the brain, and usually from the internal car in cases of otorrhea. 

The disease seems to have sometimes occurred in an epidemic form. 
There is reason to believe, however, when we consider the purely sporadic 



504 SIMPLE MENINGITIS. 

nature of its recognized causes, that the reported epidemics have for the 
most part been of cerebro-spinal meningitis, a disease which we shall treat 
of in its appropriate place, among the acute specific febrile affections. 

Anatomical Lesions. — The dura mater is generally much injected, and 
its sinuses, together with the large cerebral veins, contain coagulated or 
semi-coagulated blood, sometimes in large quantities. On opening the 
dura mater, the w^hole, or nearly the whole of the convex surface of both 
hemispheres, or in some instances of one only, are found to be covered with 
a yellowish or greenish-yellowish layer, which consists of fluid or concrete 
pus, or of false membranes. These deposits exist also on the internal sur- 
faces of the hemispheres, on the upper surfaces of the cerebellum, and often 
also at the base of the brain, though in some cases the latter presents none 
whatever. The inflammatory products are seated in the pia mater, and 
sometimes in the cavity of the arachnoid membrane, but in much smaller 
quantity than in the tissue beneath that membrane. 

The arachnoid membrane which covers the brain seldom participates in 
the inflammation, but remains smooth and transparent. Its cavity, how- 
ever, sometimes contains inflammatory products, which, when death occurs 
early in the attack, consist of a small quantity of pure pus, or of larger 
quantities of a turbid, yellowish serosity, consisting of serum and pus mixed 
together. "When death has occurred later in the disease, — after five, six, 
or seven days, — the pus is mixed with lymph, or else true false membranes 
are found. The pia mater is observed to contain fluid or semifluid pus 
when death occurs before the fourth or fifth day ; while in less acute cases 
there are patches or large layers of lymph, which sometimes dip into the 
anfractuosities, and give to the membrane under consideration a swelled 
and thickened appearance. These appearances are more marked on the 
superior and lateral, than on the inferior surface of the brain. Where the 
deposits exist the membrane presents a vivid injection, which is more 
marked in proportion as death has taken place earlier in the disease. The 
pia mater is generally easily detached from the cerebral substance, par- 
ticularly when the fatal termination has occurred early. The substance of 
the brain is firm, and but slightly colored, in rapid cases. When the 
course of the disease has been slower, the cineritious portion is generally 
of a bright rose color, and the medullary substance abundantly dotted with 
red, showing that the inflammation has involved the superficial layer of 
the brain. In the latter class of cases the surface of the convolutions is 
usually softened, and the pia mater adherent. In very young children the 
whole brain is sometimes soft. 

The ventricles do not, as a general rule, contain transparent serum, ex- 
cept at a very early age, when serous effusion takes place with great 
facility. They, often, however, contain one or two teaspoonfuls, and 
rarely more than one or two tablespoonfuls, of pus or purulent serum. 
The serous membrane of the ventricles and the plexus choroides exhibit 
signs of inflammation in some instances. They are of a bright red color, 
uneven, rough, and very much softened, in children who die early ; and 
pale, opaque, slightly thickened, and rough, in those who die at a later 
period. 



I 



SYMPTOMS. 505 

The central parts of the brain often retain their firmness, bnt are some- 
times softer than natural, or even diffluent. This softening is particuhirly 
apt to exist in very young children, in connection witli large efiusion into 
the ventricles; though it also occurs in those ^vho are older, and in whom 
there is only slight effusion of ])us or purulent serum. In the former case 
it is probably due to the macerating effect of the effusion, ^Yhile in the latter 
it is more likely to be owing to inflammatiou. 

lu some cases, and especially those of the epidemic form of the disease, 
the membranes of the spinal cord are found to present the same inflamma- 
tory appearances which have been described as existing in the cerebral 
meninges. Tliese cases are, therefore, more correctly designated by the 
name cerebro-spinal meningitis. 

The other organs are healthy except in secondary cases. Tubercles, 
which so constantly exist in various other organs in tuberculosis of the 
meninges, are never found, according to M. Eilliet, in this form of menin- 
gitis. This author believer himself entitled from his researches to formu- 
late the following law of pathological anatomy: "That general meningitis 
and meningitis of the convexity of the brain ocoir only in non-tuberculous 
children, whilst meningitis of the base of the brain without inflammation 
of the lining membrane of the ventricles, belongs exclusively to tubercu- 
lous children." ( Op. cit., t. iii, 1846, p. 408.) 

This law cannot, however, be adopted without exception, since we have 
already seen, when speaking of tubercular meningitis, that there are, in a 
large proportion of such cases, evidences of inflammation of the lining 
membrane of the ventricles. 

Symi»toms. — The following account of the symptoms of the disease is 
taken chiefly from the paper of M. Rilliet. That author describes two 
forms of the affection, the convulsive and phrenitlc; the former of which 
is characterized by a predominance of convulsive phenomena, and the 
latter by disorders of the intelligence. 

The disease may also be idiopathic or secondary, simple or complicated, 
sporadic or epidemic. 

The convulsive form generally occurs in children under two years of age. 
The disease usually begins suddenly or after a restless night, with a violent 
and prolonged attack of convulsions, oftener general than partial, and is 
accompanied by violent fever, and sometimes by considerable quickness of 
respiration. The existence of headache cannot be ascertained at this early 
age. Vomiting is often absent, and the boweh generally continue regular 
in thjs form, though they are sometimes constipated. After awhile the con- 
vulsions cease, and the child remains for the time in a state of quiet, som- 
DoleDce, or coma, when they return with renewed violence. The returns of 
the convulsions generally take place at intervals of one or two hours or 
more. In the intervals between the crises the child is restless or drowsy, 
or in a state of partial stupor, attended with tremulous movements of the 
extremities ; there is strabismus, contraction of the jfupils, trismus, and some- 
times hemiplegia. The skin retains its warmth, the pulse is accelerated, 
irregular, and unequal ; the face is pale ; the stools are spontaneous or 
ea.«ily procured by remedies. It is unusual to see the child regain its con- 



506 SIMPLE MENINGITIS. 

sciousness so as to recoguize objects in the intervals between the convulsions, 
or after the appearance of coma and other cerebral symptoms. Death occurs 
during coma or in a violent attack of convulsions. This form seldom lasts 
more than four days. 

Occasionally this form begins in a different manner. The convulsions, 
though they still predominate, do not occur until later in the disease, and 
the whole course of the affection is slower. Such cases begin with a violent 
febrile movement, lasting several days, and accompanied by acceleration 
or uneveuness of the respiration, or by almost constant drowsiness, pre- 
ceded or followed by agitation, screaming, staring expression of the eyes, 
and dilatation of the pupils ; vomiting and constipation are sometimes 
present, at others absent. After a time, however, convulsions make their 
appearance, and the case follows the course already described. The du- 
ration of this form may be the same as that of the first, or it may last 
about two weeks. 

The phrenitie form of simple meningitis generally begins suddenly with 
fever, which is sometimes preceded by a chill ; the skin is warm and dry, 
and the pulse, in idiopathic cases, full and accelerated. In secondary 
cases the pulse has been found slow and irregular ; in all it becomes ir- 
regular, small and very rapid the day before death. Simultaneously 
with the fever there is frontal headache, which is often so violent as to 
draw cries from the child, and, according to M. Killiet, is more severe than 
either in tubercular meningitis or typhoid fever. It is also more constant, 
and lasts generally one, two, or three days, until the appearance of rest- 
lessness, delirium, or coma. At the same time there is great sensibility to 
light and noise, and abundant vomiting of bilious matter. The latter 
symptom is one of the earliest ; it generally ceases after a few days, but 
sometimes continues to the very end. Constipation exists in some cases, 
but is much less constant and more easily overcome than in the tubercular 
disease. The appetite is lost, and the thirst very acute. The abdomen is 
flattened and retracted, especially towards the end, while in secondary 
cases of this form, and in very young children, it retains its usual shape. 

About the end of the first day, generally, or, in rare instances, after two 
or three days, appear various disorders of the intelligence. The first symp- 
tom of this kind is observable in the expression of the face, w^hich becomes 
a little wild or wandering, and sometimes grimacing. Soon afterwards 
occur restlessness, which is sometimes extreme, and, in succession, delirium, 
somnolence, and later in the attack, coma. The restlessness and somno- 
lence often alternate early in the case, though the former generally pre- 
dominates and soon passes into delirium, which is usually violent. When 
in this condition the child seldom recognizes any one, and either refuses 
to answer questions, or answers incoherently. In connection with the dis- 
orders of intelligence there exist also trismus, grinding of the teeth, sub- 
sultus tendinum, partial convulsive movements, stiffening of the extremi- 
ties or trunk, retraction of the head, strabismus, contraction first and then 
dilatation of the pupils, and in some cases violent convulsions, followed by 
deep coma. Death sometimes occurs at this period. In other instances, 
the disease continues longer, and other symptoms declare themselves. 



DIAGNOSIS. 507 

Vomiting generally ceases ; constipation increases ; the abdomen is re- 
tracted ; headache is no longer complained of; the fever continues, but 
the pulse becomes irregular; the respiration is uneven and irregular, 
being sometimes more and at other times less frequent than natural ; the 
face is distorted and extremely pale, or there may be a purple flush on the 
cheeks; the restlessness is excessive, and accompanied by subsultus, car- 
phologia, or partial convulsive movements ; tlie delirium, at first so violent 
as to make it necessary sometimes to hold the child in bed, subsides into 
a state of coma and collapse, in which general sensibility is obtunded, and 
special sensibility extinguished ; the respiration becomes stertorous, and 
at length asphyxia, coma, or a severe attack of convulsions terminates 
the scene. 

The course of the disease is generally continuous. In very rare cases, 
however, occasional remissions occur, so that the child recovers its intelli- 
gence for a short time, and recognizes persons around. The duration has 
varied between a day and a half and nine days. 

Diagnosis. — The convulsive form may be confounded with the essential 
or symptomatic, and with the sympathetic convulsions of children. The 
mistake may generally be avoided by attention to the following points. 
In essential convulsions, the attacks are usually less violent, seldom last 
more than a few moments, occur from some evident cause, and do not recur 
often. When they have ceased, the child generally soon regains its con- 
sciousness and health, or exhibits slight drowsiness, or derangement of 
movement for a short time only. In such cases the respiration is not per- 
manently accelerated, as in convulsive meningitis ; the pulse, if it has been 
increased in fcequency, soon falls to the natural standard, and special sen- 
sibility remains undisturbed. 

It is to be distinguished from sympathetic convulsions by the characters 
just described, aided by a reference to the disease which may have caused 
the attack of eclampsia, and which may be one of the eruptive fevers, en- 
teritis, indigestion, pneumonia, or any other acute affection. In some 
instances, however, the distinction cannot be made except by attention to 
the progress of the attack. 

The phrenitic form may be confounded with tubercular meningitis, with 
congestion of the brain, or with the early stage of the eruptive fevers. The 
distinction between it and tubercular meningitis has already been consid- 
ered under the head of the latter disease. 

It i.s sometimes difficult, as pointed out by Rilliet, to distinguish between 
simple meningitis and cerebral congestion and partial encephalitis. 

In congestion, however, there is not the same intense headache, the 
' :!c movement is not so marked, vomiting is usually al)sont, and the 

-v iopment of delirium or coma, or of convulsive or paralytic -ynijjtoms 
is more sudden or even instantaneous. 

Partial encephalitis is even more rare in children than sim|»l<; m< iiin- 
gitis. It may be distinguished from the latter by the less severity of the 
headache, by the less marker! delirium, by the comparative infrequency of 
vomiting, and by the less activity of the febrih- movement, and the more 
gradual course of the case in encephalitis. 



508 SIMPLE MENINGITIS. 

From the invasion of variola, it is to be distinguished by attention to 
the contagious and epidemic nature of that malady, by the inquiry as to 
whether the patient has been vaccinated or has had a prior attack of that 
disease, by the absence of pains in the loins in meningitis, and by a con- 
sideration of the period at which the delirium makes its appearance, which, 
in variola, rarely occurs before the third day. To make the diagnosis 
between meningitis and malignant scarlatina, we must attend chiefly to 
the epidemic and contagious character, to the thick coating upon the 
tongue, redness of the throat, elevated temperature, and nasal respiration, 
which exist in the latter. 

Prognosis. — The prognosis of simple meningitis is very grave, but 
much less hopeless than in the tubercular form. M. Valleix is disposed 
to think that most of the recoveries reported by M. Guersant were cases 
of sanguine congestion or effusion. M. Rilliet {loc. cit.), who has studied 
the subject more carefully than any other observer, cites several instances 
of recovery, but states that death is much the most frequent termination. 

Treatment. — It must be evident, it seems to us, that but little depen- 
dence can or ought to be placed on any but prompt and powerful anti- 
phlogistic treatment. Bloodletting, therefore, mercury, cold applications to 
the head, purgatives, counter-irritants, and the most rigid diet, ought to be 
employed from as early a period as possible, and in the most energetic 
manner. 

Venesection ought always to be preferred to local bleeding, even in the 
youngest child, unless it is impossible to find a vein, or unless this is evi- 
dently too small to bleed well. When venesection cannot, from any rea- 
son, be employed, blood should be freely drawn by means of leeches or 
cups. It is customary to apply the leeches to the temples or behind the 
ears. We may remark that MM. Rilliet and Barthez object to the appli- 
cation of leeches to the head, and propose that they should be placed rather 
about the anus or on the inferior extremities. The quantity of blood to 
be drawn must depend upon the age and constitution of the subject, and 
the violence of the attack, in some measure. It should always, however, 
be large, as much or more, we think, than is necessary in any other of the 
acute affections of childhood. In a child two years old, of good consti- 
tution, from two to four ounces would not be too much at first, and should 
the symptoms not moderate in six or eight hours, as much more may be 
taken. Should these detractions of blood fail to produce a good effect 
upon the dangerous symptoms, it would be proper, unless there were evi- 
dent and unmistakable signs of exhaustion, to take still more, either lo- 
cally or generally. We are disposed to believe that in such a disease as 
this, bleeding is by far the most powerful remedy, and it is perhaps the 
only one which offers us any real chance of success, at least in those rapid 
cases in which extensive layers of pus and false membranes are found on 
the surface of the brain, in the pia mater, or in the subarachnoid tissue, 
in from two days and a half to three or four days after the commencement 
of the disease. 

While the bleeding is being performed we should direct the preparation 
of means for the application of cold to the head, which constitutes another 



TREATMENT. 509 

most efficient remedy iu inflammations of the brain and its membranes. 
These means may consist of a bh\dder containing water and pounded ice, 
which is perhaps the most convenient and powerful, of cloths wrung out 
of iced or very cold water, to be constantly renewed, of cold affusions upon 
the head, or lastly, of irrigation as recommended by M. Guereant, and 
described in the article on tubercular meningitis. Purgatives ought to be 
employed so as to empty the bowels thoroughly, and produce a decided 
revulsion upon the intestinal mucous membrane, but not in such quantity 
as to occasion inflammation of that tissue, which would be very apt to 
prove the case were the drastic substances and large doses recommended 
by some writers used. The remedy usually given and most highly recom- 
mended is calomel, which is chosen for its sedative alterative properties. 
About four grains may be exhibited alone, and followed in one, two, or 
three hours by castor oil, jalap, or infusion of senna and manna, sweetened 
with syrup of rhubarb. These doses ought to be given until the bowels 
are freely moved. It is always useful to employ a strong purgative enema 
immediately after the bleeding, without waiting for the operation of the 
internal remedies. After the purgative doses have been given, it is impor- 
tant to continue the mercury in smaller quantities, with the view of ob- 
taining it5 specific influence upon the inflammation. The doses may con- 
sist of from a quarter of a grain to a grain every hour or two hours. Some 
writers also recommend very highly the use of mercurial inunction. Vogel 
{op. cit., p. 361) states that a mercurial treatment is decidedly effectual, 
and adds that the only two children he has seen recover from this disease, 
were treated exclusively with mercury, internally and externally. 

Counter-irritants are useful as adjuvants to the more powerful remedies 
already indicated. During the first day or two they should consist chiefly 
of sinapisms and mustard poultices, applied from time to time to the trunk 
and extremities. Authorities difler somewhat as to the effect of blisters, 
and as to the time at which they ought to be applied. M. Valleix (op. 
cit.j t. ix, p. 187j, opposes their employment in this affection as often inju- 
rious and still more frequently useless. We think the advice given by 
Dr. Abercrombie, as to their employment, is probably the most prudent. 
This is, not to apply them in the early stage, but to wait until the active 
symptoms of the disease have been subdued. They may be applied to the 
head itself, to the nucha, or to the extremities. We believe that we have 
seen them most useful when applied to the neck and inside of the calves 
of the legs. Nevertheless, there is high authority in favor of their good 
effects when applied upon the head itself. 

M. Rilliet (loc. cit.) recommends a vigorous revulsion upon the scalj) 
when the disease has followed the suppression of an eruption. He proposes 
with this view the employment of pustulation by croton oil, and relates a 
ra>e of recovery which followed this treatment under a most unfavorable 
train of symptoms. To make use of it the head must be first sliaved ; 
from fifteen to twenty drops of the oil are then to be rubbed over the 
scalp with a glove four or six times a day. Before making the friction, 
the eyes of the patient must be covered with a band to prevent the intro- 
duction of any of the oil into them, as this would be apt to occasion severe 



510 



CEREBRAL CONGESTION. 



ophthalmia. In the case reported by him, a considerable number of pus- 11 
tules were produced in twenty-four hours, and in a few more hours the 
eruption was general, so that the head was covered with a kind of cap of 
a fine yellow color. 



ARTICLE III. 



CEREBRAL CONGESTION. 



Cerebral congestion implies a condition in which the bloodvessels of 
the brain contain an excessive quantity of blood. It occurs under the two 
forms, of active congestion, where there is an increase in the amount of ar- 
terial blood, and of passive congestion, where the quantity of venous blood 
is excessive. 

While it can no longer be doubted that the amount of blood circulating 
in the brain is thus liable to vary, and that such variations are of frequent 
occurrence, and are attended with very important symptoms, it is difficult 
to determine the relative frequency of cerebral congestion at different pe- 
riods of life. Dr. West, whose publications upon the diseases of children 
are amongst the most valuable that the English press has afforded us, long 
ago claimed for cerebral congestion in childhood the position of a very 
important and frequent condition of disease. According to some more 
recent authors, also, it is much more frequent in childhood than at any 
later period of life. We are inclined, however, to regard this latter view 
as probably an overestimate, because, in our opinion, the symptoms which 
are detailed in this article as dependent on congestion of the brain, are, in 
some cases, rather due to mere excitement and undue rapidity of the cir- 
culation, and in others to the irritation of the brain caused by the circu- 
lation through it of blood vitiated by the poison of some of the acute 
specific diseases. 

Rilliet and Barthez assert (lere edit., t. i, p. 649) that they have found 
in children dying of different diseiases, and who had presented no cerebral 
symptoms, congestion precisely similar to what they found in others who 
had exhibited more or less dangerous idiopathic or secondary nervous 
symptoms. They are not disposed, therefore, to attribute to cerebral con- 
gestion any large share in the production of eclampsia or other nervous 
phenomena. Other writers of the French school, also, as Valleix and the 
authors of the Bibliotheque du Med. Prat, express the view that it is rare 
to meet with true pathological and idiopathic congestion of the brain, 
either in the first or second infancy (t. vi, p. 118). We have alluded to 
this diversity of opinion not to depreciate the importance of this condi- 
tion, but to show how much want of agreement exists among high authori- 
ties as to th^ explanation of symptoms (delirium, somnolence, coma, con- 
vulsions, etc.), which we believe are too often, in this country, set down as 
unquestionably dependent on cerebral congestion. 



CAUSES — SYMPTOMS. 511 

Causes. — Active congestion may occur during the process of dentition, 
or may result from exposure to the sun, from falls or blows on the head, 
or from excessive excitement or fatigue iu child reu who are predisposed to 
the affection. The cerebral symptoms occurring at the outset of the erup- 
tive fevers have been, by West and others, attributed to the development 
of intense cerebral congestion. AVe feel, however, that the nervous symp- 
toms just alluded to ought, most frequently at least, to be regarded as the 
result of the presence in the nervous centres of a diseased and vitiated 
blood, rather than of congestion. That congestion does not always pro- 
duce them is shown by the statement of Rilliet and Barthez (op. cit., t. ii, 
p. 620) in regard to the cerebral symptoms of scarlet fever, " that a more 
or less sanguine congestion (of the cerebro-spinal apparatus) is the only 
alteration generally, but not ahcays found, and sometimes the congestion is 
not more marked than in other diseases in which there had been no cere- 
bral symptoms." 

In reference to the cerebral symptoms which less frequently occur in in- 
flammations of important organs, as, for instance, pneumonia or entero- 
colitis, we are not yet in possession of sufficient facts to determine whether 
they result from reflex irritation, from the elevated temperature and ac- 
celeration of circulation, or from changes in the quantity of blood circu- 
lating through the brain. Probably all three of these elements take part 
in varying proportion in the production of such symptoms ; we do not, 
therefore, feel at liberty to regard them, in the majority of cases, as ac- 
tually depending on cerebral congestion. 

Passive congestion results from such causes as offer an impediment to 
the reflux of the venous blood from the brain. Among them may be 
mentioned the mechanical obstruction caused by the pressure of an en- 
larged thymus gland, or of enlarged cervical or bronchial glands, or by 
the partial or complete occlusion of a large vein or sinus from the forma- 
tion of a fibrinous concretion (thrombosis) in its cavity, or from the pres- 
sure of a tumor upon its walls. Passive congestion occurs also in affec- 
tions which, like hooping-cough, are attended with violent paroxysms of 
cough, during which the return of venous blood from the brain is greatly 
impeded. Finally it often appears that the state of feeble, languid circu- 
lation, depending upon want of pure air or of sufficient and nourishing 
food, strongly predisposes to, or actually induces, this form of cerebral 
congestion. 

Symptoms. — Recognizing that cerebral congestion may occur at the 
outset or during the course of various acute diseases, it is evident that the 
symptoms due to the congestion itself must frequently be complicated by 
those of the primary affection. We may, however, give the following 
brief sketch of the symptoms which may be attributed to the two forms 
of cerebral congestion. 

The active form usually appears suddenly, though it may be preceded for 
a few days by a state of indisposition, with irritability and peevishness, 
some fever, and a disordered state of the bowels generally, l)ut not always 
consisting of constipation. The chief symptoms of the attack are great heat 
of the head, and complaint", in older children, of headache, intolerance of 



512 CEREBRAL CONGESTION. 

light and sound, nervousness, with startings during sleep and twitchings of 
the muscles. The pulse is frequent, the carotids throb, and if the skull be 
still unossified the anterior fontanelle is tense and prominent, or the brain 
is seen and felt to pulsate forcibly through it. If these symptoms be not 
relieved by appropriate treatment, or, in some cases, without any premoni- 
tory stage, the child may pass into a state of more or less profound stupor 
or coma ; or, on the other hand, an attack of partial or general convulsions 
may occur. 

In passive congestion the symptoms are apt to be less suddenly devel- 
oped, but when marked they resemble in many respects those which we 
have described as indicative of the active form. There is, however, less 
febrile excitement, and the force of the arterial pulsation and the promi- 
nence and tension of the fontanelle are notably less. Still there are 
usually present great irritability, restless, disturbed sleep, muscular twitch- 
ings, or even convulsions ; or, on the other hand, deepening indifference 
to surrounding objects, resulting in profound stupor. 

The duration and termination of these symptoms are very variable. If 
the anatomical condition present has been only one of great vascular dis- 
tension, and appropriate treatment is promptly employed, the threatening 
symptoms subside in the course of two or three days. If, however, the 
congestion has been so extreme or has lasted so long as to lead to serous 
effusions or even to minute extravasations of blood, the symptoms may 
continue to deepen in gravity until the fatal result occurs, or else the at- 
tack subsides but leaves behind it some evidence of injury to the brain- 
tissue in the form of more or less lasting paralysis. Occasionally, how- 
ever, complete recovery takes place, contrary to all expectation, after the 
grave symptoms above described have continued but slightly modified for 
days or even weeks. 

The diagnosis of cerebral congestion must be based upon the symptoms 
above detailed, as well as upon the general considerations with which we 
^ prefaced this article. The reader is also referred to the remarks made 
under the head of diagnosis in the article on simple meningitis. It is, of 
course, essential not only that the existence of cerebral congestion should 
be recognized, but also that the form in which it presents itself should be 
determined, as this has a most important bearing upon, the treatment to be 
employed. 

Treatment. — Active cerebral congestion is to be treated like the first 
stage of simple meningitis, with cathartics and purgative enemas, calomel, 
cold applications to the head, baths, revulsives, full doses of bromide of 
potassium, low diet, and confinement to a cool dark chamber. We desire 
to lay particular emphasis upon the employment of bromide of potassium, 
as its power of lessening active congestion of the nerve-centres is estab- 
lished by very positive evidence. Belladonna, which exerts a similar 
action, may be associated with it. If the symptoms do not promptly 
yield to these measures, and there is no special contraindication, we 
should recommend the use of local depletion by leeches or wet cups to the 
temples or some part of the head. 

In the treatment of the passive form, particular attention must be given 



CEREBRAL HAEMORRHAGE. 513 

to the relief or removal of the primary cause. Unfortunately, however, 
in many instances this is not possible. The urgent symptoms themselves 
must be promptly treated by coki applications to the head, by active re- 
vulsion, by strict attention to the diet and the state of the bowels. If 
great danger exists, and the nature of the cause and the condition of the 
child justify it, mild local depletion may be cautiously employed. If, on 
the other hand, the case be associated with enfeebled nutrition, it may be 
necessary to employ quinia, ammonia, as nourishing a diet as can be di- 
gested, and small amounts of stimulus. 

If the congestion terminate in extravasation, the treatment for this con- 
dition and the paralytic symptoms which may result, must be such as is 
i recommended under the head of cerebral hiemorrhage. 
; 



ARTICLE IV. 

CEREBRAL HEMORRHAGE. 



We shall consider haemorrhage of the brain under two heads, that of 
the substance, and that of the membranes ; the former is usually desig- 
nated as cerebral, and the latter as meningeal apoplexy. Both these forms 
of hiemorrhage are of rare occurrence in childhood compared with other 
diseases of the brain, and with their frequency during adult life and old 
age. Of the two kinds, that of the meninges is the most common. 

Definition; Frequency; Forms. — By cerebral apoplexy or haemor- 
rhage is understood an effusion of blood into the substance of the brain. 
By meningeal apoplexy or hiemorrhage is understood an effusion of blood 
between the dura mater and cranium, into the cavity of the arachnoid 
membrane, beneath the arachnoid, or in the meshes of the pia mater. 
Cerebral haemorrhage is a very rare affection in childhood. This is 
proved to be the case by the facts that MM. Rilliet and Barthez met with 
only eight cases in their extensive experience, and that M. Barrier saw 
but one in 576 cases of disease of all kinds. Meningeal apoplexy is of 
more frequent occurrence, since MM. Rilliet and Barthez report eighteen 
cases. M. Barrier. met with one case of this form in the 576 cases referred 
to. Dr. West (London Med. Gaz., June 18th, 1847, p. 1062) says he has 
only twice met with distinct extravasation of blood into the substance of 
the brain in children. We have ourselves met with two cases of hiemor- 
rhage into the substance of the brain, and with several of meningeal apo- 
plexy. 

Haemorrhage into the substance of the brain occurs in two different 
forma: one in which the effused blood is contained in a cavity cau.-ed by 
a laceration of the tissue of the organ, and der^ignated apoplexy in a cavity; 
and the other in which the blood is effused in a multitude of little points 
of different sizes, and designated capillary apoplexy. 

In addition to thi.s, as in a remarkable case published by Dr. Dulles 
(J'], ',!.,. hi. Med. Times, July 22d, 1876;, the hiemorrhage may occur into 
the veDtricles of the brain, completely filling these cavities. 

33 



514 CEREBRAL H JilMORRHAGE. 

In meningeal hsemorrhage the blood may, as we have stated, be effused 
between the dura mater and the bone. This form, however, is very rare, 
so rare, indeed, that several writers deny its existence. It is proved, how- 
ever, to have occurred, by a case reported by MM. Rilliet and Barthez, 
which is the only one they have met with. In by far the most common 
form of the disease, the blood escapes into the cavity of the arachnoid 
membrane. Of this form the authors just quoted report 17 cases, while, 
according to the authors of the Bibliotheque du Med. Prat. (t. vi, p. 193). 
the effusion always occurs in this situation. That this is not invariably 
correct, however, is proved by the case of effusion exterior to the dura 
mater already referred to, and by the fact that it sometimes takes place be- 
neath or in the meshes of the pia mater. The latter class of cases is very 
rare, however, in proportion to those in which the hsemorrhage occurs 
within the cavity of the arachnoid. MM. Rilliet and Barthez did not 
themselves meet with a single instance of that kind, but they quote two 
from other writers ; and M. Valleix refers to a memoir by M. Prus, in 
•which others are given. It appears, therefore, that in the great majority 
of instances, the effusion takes place within the cavity of the arachnoid 
membrane. 

Causes. — The causes of cerebral hsemorrhage are very obscure, so much 
so, indeed, that some writers have not attempted to ascertain them. They 
appear to be the same in both forms of the affection. Amongst the as- 
cribed causes are the sudden disappearance of eruptions of the scalp, ob- 
served in two cases by MM. Rilliet and Barthez, in one of which this effect 
is stated to have been produced suddenly by medical treatment, while in 
the other it followed the application of poultices to a favous eruption upon 
the same part. This cause must, however, it appears to us, be regarded as 
purely illusory. The disease is stated by M. Legendre to have followed in 
one case a violent fit of anger. It is said also to have been produced by 
various causes which acted as impediments to the circulation. The obsta- 
cle may be situated within or exterior to the cranium. To the first class 
belong cases in which the sinuses and large venous trunks of the head have 
been found obstructed by coagula of blood, or by the pressure of tumors, 
generally of a tubercular nature ; to the latter, those in which there is in- 
tense engorgement of the superior cava produced, as in prolonged parox- 
ysms of hooping-cough, or in obstructive cardiac disease, or where there is 
compression of this vessel by enlarged and tubercular bronchial glands. 
Another cause is thought to be the existence of confirmed cachexia and 
general debility from any diseased condition whatever, in which the blood 
having become thin and lost its plasticity, escapes from the vessels with 
great facility. This last condition is one which almost always exists in 
connection with the causes cited as acting through the agency of obstruc- 
tion to the circulation, and tends of course to augment their dangerous 
effects. Occasionally, also, aneurisms of the cerebral arteries, especially of 
the middle cerebrals, occur at an early age (several cases are on record at 
the age of 14 years), and by the rupture of the sac give rise to excessive 
and rapidly fatal cerebral hsemorrhage. 

We have met with one case of extensive hsemorrhage into the left corpus 
striatum and adjoining tissue in a boy of 13, evidently connected with ad- 



ANATOMICAL LESIONS. 515 

vanccd granular degeneration of the kidneys, resulting from a previous 
attack of scarlatina. 

In some instances the haemorrhage occurs in the healthiest and most 
vigorous constitutions, and cannot be accounted for in any way. 

It appears that meningeal apoplexy is most frequently met with in very 
young children, according to MM. Rilliet and Barthez, between the ages 
of one and two and a half years, whilst M. Legendre did not meet with a 
single case after three years of age in 248 autopsies. Cerebral and ven- 
tricular ha}morrhage, on the contrary, are much more common after three 
years of age than before, which is just the reverse of the law in regard to 
meningeal effusion. 

Anatomical Lesions. — The description of the lesions of hcemorrhage 
into the substance of the brain need not detain us long, for they are much 
the same as those observed in the adult. When the blood is eff'used into 
cavities (apoplexy in cavities), the latter are usually small in size, seldom 
exceeding from one to two-thirds of an inch in diameter, though in rare 
cases they have been found much larger. The cavity is formed by a lacera- 
tion of the substance of the brain, and is filled with soft, dark coagula, or 
sometimes with fluid blood; the walls of the cavity consist sometimes of the 
•ubstance of the brain, which may be of a rosy color and natural consist- 
ence, or yellowish and softened, while in other instances they are formed 
of more or less numerous points of capillary apoplexy. The capillary form 
of eflfusiom occurs in the shape of a number of points, scarcely so large as 
the head of a small pin, and of a dark or brownish color, which contrasts 
strongly with that of the cerebral tissue. These points evidently consist 
of true coagula, which are sometimes surrounded by small yellowish areolae. 
The substance of the brain around the effiision is either white, firm, and 
perfectly healthy, or softened, and of a whitish, reddish, or yellowish color. 
The capillar}' effusions are generally limited within a space of from a third 
of an inch to an inch and a half in size, but they have been found scat- 
tered over a large portion of the hemispheres. 

Both forms of hiemorrhage are much more common in the cerebrum 
than cerebellum, and occur more frequently on the left than right side. 
In addition to the sanguine effusion there is generally considerable con- 
gefstion of the pia mater, of the venous sinuses, or of the substance of the 
brain itself. 

In describing the lesion? of meningeal apoplexy, we shall confine our re- 
marks to the effu.-ion which occurs into the cavity of the arachnoid, this 
being, as we have already remarked, by far the most frequent form of the 
di.«ease. 

The appearances presented by the cavity of the arachnoid into which the 
effusion has taken place vary greatly in different cases, according to the 
age of the child, the quantity of the hiemorrhage, and the period of time 
which may have elapsed between the accident and the death of the patient. 
It is very uncommon to find pure liquid blood, though this has been met 
with. In the case published by Dr. Dulles (loc. oH.), which occurred at the 
age of six months, the lateral ventricles were filled completely with firm 
and partly organized clots, a large firm clot filled the third ventricle. 
The surrounding brain tissue was deeply stained, but was not lacerated. 



516 CEREBRAL HEMORRHAGE. 

In most instances, there is a bloody serum mixed with thin, reddish coag- 
ula, contained in a soft and very delicate membrane lining the internal 
surface of the arachnoid. Sometimes the effusion is thin, limpid, and more 
or less yellowish in color, while at other times it is thick and brownish, or 
chocolate-colored. In some rare cases it is perfectly transparent and color- 
less. The fluid, in whatever state it exists, appears to be the result of 
transformations undergone by the effiised blood. The solid portion of the 
blood or clot is found either in the condition of more or less recent coagula, 
or changed into false membranes, which sometimes resemble very closely 
the arachnoid itself, and sometimes a true fibrous membrane. The coag- 
ula are found in the form of thin membranes, varying between one or two 
lines in thickness, and an inch and a half to two inches in size. They are 
thickest generally in the centre, where they measure between a fifth of a 
line and two lines, and are brownish or greenish in color, and of variable 
consistence, according to their age. These coagula may exist upon any 
portion of the brain, but, according to MM. Rilliet and Barthez, are most 
frequently met with upon its convex surface. 

The coagula just referred to undergo in some instances a curious change, 
of which we shall give a short description. In the course of time, the 
fibrinous portions of the blood are deposited upon the internal surfaces of 
the cavity of the arachnoid, in the form of a new membrane. When death 
occurs soon after the onset of the attack, the parietal layer of the arachnoid 
is found to be completely lined with this raembraniform production, whilst 
the visceral or cerebral layer is covered by it only in certain points. When 
the case has lasted a longer time, on the contrary, the visceral as well as 
the parietal layer of the arachnoid may be covered with the new produc- 
tion, and when this happens there is formed a true sac or cyst, destitute of 
opening, which lines the whole interior of the arachnoid, and contains 
within its cavity bloody serum and coagula. At first this new membrane 
is reddish in color, elastic, and of a stronger texture than might be sup- 
posed from its apparent thinness and softness. Its thickness is generally 
about a tenth of a line. At a later period the walls of the cyst become so 
thin and transparent that they have been mistaken for the arachnoid it- 
self They differ, however, from the latter in being rather less transparent 
and thin, and particularly in the circumstance of presenting numerous vas- 
cular arborizations. When death occurs at this stage, which M. Legendre 
(whose description we chiefly follow) calls the second period, or that of 
complete organization of the cyst, the external surface of the latter is found 
to adhere intimately to the parietal portion of the arachnoid membrane, 
by very delicate cellular tissue, though not with so much force but that it 
may be detached by traction. The internal portion of the new membrane, 
on the contrary, which is lubricated by the serosity of the arachnoid tissue, 
is very slightly adherent to the layer of that membrane covering the brain. 

So long as the cyst formed by the new membrane, or, as it is called by 
MM. Killiet and Barthez, the 'pseudo-arachnoid membrane, contains an 
amount of fluid sufficient to keep its surfaces separated, its cavity is single. 
When, on the contrary, the walls of the cyst have come into contact, either 
because of the partial absorption of the contained fluid, or because the fluid 
has accumulated at the lowest points, or wherever there is the least resist- 



SYMPTOMS. 517 

ance, the cavity becomes multilocular iu consequence of the cohesion of its 
walls at certain points. 

The size of the cyst varies exceedingly. Sometimes it covers the greater 
part of the convex surface of one hemisphere, sometimes the whole, while 
in other instances it extends to the base, forming in that case a nearly com- 
plete shell for the whole brain. The quantity of fluid varies in diftereut 
cases. Sometimes it amounts only to a few large spoonfuls ; in others, to 
one or two, or eight or nine ounces; in one case observed by MM. Rilliet 
and Barthez there was upwards of a pint on each side, or more than a 
quart in all. In most instances the hremorrhage occurs into both halves 
of the arachnoid membrane, so that there is a cyst for each hemisphere. 
More rarely it occurs only on one side. 

In the second stage, and when the effusion is very large, which rarely 
happens except in young children, and prior to ossification of the fonta- 
nelles or sutures, the lesion constitutes a form of chronic external hydro- 
cephalus, and the symptoms are such as will be detailed under the head 
of this latter disease. The vault of the cranium is enlarged by the un- 
natural prominence of the frontal and parietal bones ; the sutures are 
more open than usual, and the anterior fontanelle is distended and pro- 
tuberant. When the etfusion occurs thus early in life before complete 
ossification of the skull, the brain does not appear compressed or flattened, 
as it does when the disease occurs at a later period. 

The visceral portion of the arachnoid is often thickened, opaque, and 
more resisting than natural. The pia mater is frequently infiltrated with 
a good deal of serosity, which sometimes has a gelatinous appearance. 
When death has occurred in the first stage of the disease, the brain usually 
presents signs of hyperemia. The veins on the surface of the hemi- 
spheres are enlarged, the cortical substance is of a bright rose-gray color, 
and the medullary ix)rtion is dotted over with drops of blood. Sometimes 
the cellular substance beneath the arachnoid is slightly infiltrated with 
serosity, at other times not. The ventricles contain a very small quantity 
of fluid. 

The exact anatomical cause of the cerebral hiemorrhage in children is 
still subject to some doubt. It appears probable that it usually results 
from intense determination of blood to the head, or from extreme passive 
congestion, which lead to the rupture of vessels so minute as to escape 
notice, or possibly in some cases to the transudation of blood through the 
capillar}' walls without actual rupture. We are not aware that any care- 
ful micrascopic examination has yet been made of the condition of the 
walls of the vessels in such cases. In some rare instances, however, as in 
one witnessed by M. Legendre, the effusion is the result of the rupture of 
a vessel of some size. In the case observed by him, death took place in 
twelve hours from the attack, and the left hemisphere was found covered 
with a layer of coagulated blood, which had escaped from a ruptured vein. 
{Biblioth. du Med. Prat., t. vi, p. 192.) 

Symptoms; Duration. — The symptoms of htrmorrhage into the smbatance 
of the brain in the child are, as a general rule, extremely obscure and un- 
certain, though in some few cases that have been observed, they were as 
characteristic as those which occur in adults. In obscure cases, the chief 



518 



CEREBRAL HEMORRHAGE. 



symptoms that have been noticed were restlessness, delirium, headache, 
violent fever, grinding of the teeth, and, after a time, complete abolition 
of the intelligence, fixity of the eyes, invariable dilatation of the pupils, 
stertorous respiration, and general insensibility. Of three cases reported 
by M. Valleix (CUnique des Mai. des Enf,), the nature of the disorder was 
easily diagnosticated in one by the existence of complete hemiplegia, while 
in the two others the only marked symptom was entire immobility. The 
only certain symptom of the disease, therefore, would be a sudden attack 
of hemiplegia, either as the primary symptom, or following coma or con- 
vulsions, and lasting for at least several days. An attack of general 
paralysis would not be by any means so certain, as this may exist in sev- 
eral other diseases of childhood. 

In a case which came under our charge, we believe the attack to have 
been one of apoplexy of this kind. 

Case. — A girl, two years and a half old, apparently in the enjoyment of excel- 
lent health, was suddenly, and without ascertainable cause, attacked with violent 
general convulsions and entire insensibility, which lasted with very slight remis- 
sions of the convulsive movements, but without any return of consciousness, for 
twelve hours. At the end of that time the convulsions ceased entirely, and she 
very soon regained her consciousness, remaining merely peevish and languid. She 
was, however, completely hemiplegic on the left side, so that she could neither rise 
in bed, nor turn towards the right side. The paralysis diminished rapidly, but 
regularly, so that at the end of three days she could sit up in bed, and in a few 
weeks was perfectly well. This child remained well, with the exception of rather 
unusual excitability, and some peevishness of temper, for three years, when she 
died of scarlet fever. No autopsy could be made. 

The obscurity which exists in these cases will be clearly understood 
by any one who will read two examples given by Dr. West (Joe. cit., p. 
1062). 

With a short quotation from the work of MM. Rilliet and Barthez, we 
shall pass on to the subject of meningeal apoplexy. These authors remark 
{op. cit, t. ii, p. 54), in speaking of this affection, that " cerebral symptoms 
have been observed to exists but of so unusual a character, and so different 
from what have been assigned by writers to apoplexy, that they could not 
lead to a diagnosis of the disease." 

We shall describe the symptoms of the meningeal form of haemorrhage 
under two heads : first, as they present themselves in the acute, and, sec- 
ond, as they occur in the chronic or second stage of the affection. 

Unfortunately the symptoms of the acute or first stage are not much 
more certain and distinct than those of cerebral haemorrhage. The disease 
may begin with fever and some convulsive movements, or, as happened in 
a case reported by M. Valleix, with violent general convulsions. Vomit- 
ing sometimes occurs at the beginning, but is usually very slight. It is 
difficult to know whether headache exists or not at the early age at which 
this disease commonly occurs. The convulsive movements generally af- 
fect particularly the eyes, and are followed by some degree of strabismus. 
The appetite is lost from the first ; the thirst is moderate ; there is no 
constipation. Soon after the symptoms just described, appear permanent 
contractions of the hands and feet, which are followed by attacks of tonic 



11 





SYMPTOMS OF THE MENINGEAL FORM. 519 

or clonic couvulsious, during which sensibility and intelligence are abol- 
ished. Between the attacks of convulsions there is somnolence, which, 
though slight at fii^st, becomes more marked as the case goes on. The 
attacks of convulsion become more and more frequent as the case pro- 
gresses, until at last they are nearly constant. The tonic convulsions 
aftect the limbs and trunk both, but particuhirly the former, whilst the 
clonic spasms occupy sometimes one side of the body, sometimes the up- 
per extremity alone, and at other times the whole body, but even then 
are usually stronger on one side than on the other. Paralysis is rarely 
noticed in the disease ; it occurred only in one out of nine cases observed 
by M. Legendre, and in one out of seventeen observed by MM. Rilliet 
and Barthez. 

Dr. West remarks (p. 1061): "The absence of paralytic symptoms, 
however, is not the sole cause of the obscurity of these cases, but the indi- 
cations of cerebral disturbance, by which they are attended, vary greatly 
in kind as in degree. The sudden occurrence of violent convulsions and 
their frequent return, alternating with spasmodic contraction of the fingers 
and toes in the intervals, appear to be the most frequent indications of the 
effusion of blood upon the surface of the brain. I need not say, however, 
that such symptoms, taken alone, would by no means justify you in infer- 
ring that an effusion had taken place." Dr. West adverts particularly to 
the fact that apoplexy in the child is especially apt to occur in those who 
are weakly and feeble, and gives to this form of the disease the appella- 
tion of the cachectic form of cerebral haemorrhage. 

It must be remembered that in cases of valvular disease of the heart, 
embolism of one of the cerebral arteries may occur from the detachment 
of a fragment of a vegetation. We have observed this accident in a young 
girl, eight years of age, where the symptoms which marked the occurrence 
of the embolism were brief unconsciousness, followed by complete left-sided 
sudden hemiplegia. The diagnosis may be made in these rare cases by 
the detection of the physical signs of organic disease of the heart, and by 
the less severe cerebral symptoms which, as a rule, attend it. The hemi- 
plegia which follows embolism may be partial or complete. In our cases 
it persisted, with contraction of the paralyzed members, until death. 

The chronic form presents most of the symptoms which exist in acquired 
chronic hydrocephalus from .serous effusion into the ventricles. The cra- 
Dium is verj' large in proportion to the face ; the sutures are not ossified ; 
there is strabismus, with dilatation of the pupils ; the sense of sight is 
generally but not always retained; the face loses its expression; if the 
child was old enough at the moment of the attack to .show signs of intel- 
ligence, the latter are found to dimini.«h rather than increase, and some- 
times they are lost entirely, as the size of the head augments ; and the 
child is apt to utter loud cries, particularly during the night. The cutane- 
ous .sen.*?ibility is in general neither lost nor diraini.shed. The power of 
motion usually remains, though it was entirely lo.st in one ca.se. The 
apj^etite and thirst persist. 

The durnfion of cerebral apoplexy is very irregular. In one ca.se 
quoted by MM. Rilliet and Barthez, it was a quarter of an hour; in 
another, an hour ; in a third, forty-eight days; and in one reported by M. 



520 



CEREBRAL HEMORRHAGE, 



Valleix, in a very young infant, recovery was nearly perfect in a little less 
than two months, when the child was seized with pneumonia and died. 

The duration of meningeal apoplexy is also irregular. According to M. 
Legendre, all the recent cases seen by him in the Children's Hospital, died 
in from eight to twelve days, apparently rather from intercurrent diseases 
than from the primary affection itself, whilst cases occurring in subjects 
placed in better hygienic conditions, and not attacked with intercurrent 
affections, passed into the second or hydrocephalic stage of the disease. 
The second stage lasted, according to the same author, in the four cases 
which he witnessed, from eight to thirty months, and then death was the 
result, not of cerebral symptoms, but of complications affecting the thoracic 
organs. 

Diagnosis. — The diagnosis of cerebral haemorrhage is, as we have 
already stated, very difficult, unless hemiplegia exist. When the case 
commences, as it often does, with convulsions or with inflammatory symp- 
toms, it is often impossible to distinguish it from acute or tubercular disease 
of the brain. 

The diagnosis of meningeal hsemorrhage is also very often extremely 
difficult. Not uufrequently it occurs in the course of other diseases, and 
is then entirely latent. In acute, primary cases, the most important and 
distinctive symptoms are the early age of the subjects, between one and 
three years generally ; the violent fever from the commencement, marked 
by full, frequent, and regular pulse ; the absence of constipation ; the fre- 
quency of the convulsive attacks, and particularly the permanent contrac- 
tion with rigidity of the feet and hands. 

The diagnosis between the form of hydrocephalus which follows men- 
ingeal apoplexy, and ventricular serous hydrocephalus, is exceedingly 
obscure. The only circumstances which seem to have any real value are 
the acute commencement of the disease with the symptoms above detailed, 
and the early age of the patient. MM. Rilliet and Barthez state that 
they have never known a child of two years old, or younger, to die of ven- 
tricular serous hydrocephalus from tumors, whether tubercular or not, of 
the brain ; in all such cases the effusion has been the result of a haemor- 
rhage. 

Prognosis. — The prognosis of both forms of the disease is very grave. 
It is impossible, however, to ascertain the prognosis with any certainty, so 
long as the symptomatology of the two affections is so obscure as we have 
found it to be. That cerebral haemorrhage is susceptible of cure, however, 
is proved by the case reported by M. Valleix, already referred to, in 
which the child had nearly recovered, when it was seized with another dis- 
ease which destroyed it. Recovery from meningeal apoplexy is certainly 
extremely rare ; we believe, however, that we have met with one case in 
which this affection terminated favorably. 

Treatment. — The treatment must depend on the diagnosis and the 
special character of the symptoms in each case. In a sudden and severe 
attack, occurring in a strong and hearty child, in which the symptoms of 
congestion of the brain are strongly marked, and where we are not yet 
certain that actual haemorrhage has taken place, we should immediately 
resort to a general or local bloodletting. It was formerly customary to 



i 



TREATMENT. 521 

employ venesection in all such cases, but we believe that equal relief can 
be obtained by freely cupping or leeching the back of the neck. 

When, however, we have every reason to believe that blood has been 
effused either in the niembmnes or into the substance of the brain, it is 
evident that bloodletting can produce but little effect, and that only in 
reducing the general fulness of the cerebral vessels. In such cases we 
should certainly limit ourselves to the application of a few cut cups or 
leeches to the nucha. 

It must further be remarked, however, that in many cases of cerebral 
or meningeal apoplexy, depletion in any form is entirely contraindicated ; 
since, as has already been stated, the efiusiou of blood occui*s frequently 
in feeble and weakly children, and either in the course of some acute or 
chronic disease, or as a consequence of previous diseases which have ex- 
hausted the forces of the constitution and induced a state of dyscrasia and 
diffluence of the blood. In such cases as these we must depend upon the 
use of rest, cold applications, purgatives, and counter-irritants as recom- 
mended below. 

Cold applications should be immedfately made to the head, either by 
wet cloths, the ice bladder, or by cold affusion. At the same time, or as 
early as possible after the invasion, a dose of some purgative medicine 
must be given. The best is calomel, either alone or combined with jalap 
or rhubarb. If given alone, it ought to be followed in an hour or two by 
castor oil, infusion of senna and manna, salts, magnesia, or some active 
cathartic. When the symptoms are very urgent, it is well to open the 
bowels still more speedily by a purgative enema. 

Counter-irritants are always useful adjuvants to the remedies already 
mentioned. They should consist at first of mustard plasters applied to 
the extremities, and shifted from place to place. When the symptoms do 
not yield after proper depletion and the use of sinapisms for some hours, 
it is well to apply blisters to the calves of the legs, and to the nape of the 
neck. 

The diet must be very strict, and should consist only of barley or arrow- 
root water, for a few days. 

The temperature of the room should be kept cool ; and the child sliould 
be placed with the head and trunk somewhat elevated, and kept profoundly 
quiet. 

For the paralysis which follows apoplexy in children, we believe that 
the most important, and indeed the only treatment necessary, is attention 
to the general health of the patient, in order to give to nature time and 
opportunity to effect the absorption of the clot which has been thrown out 
into the .substance of the brain, or into the cavity of the arachnoid mem- 
brane. This prrK-ess may, however, be aided and hastened by the prolonged 
administration of iodide of potassium with the iodide of iron. In cases of 
meningeal apoplexy, when the disease a-ssumes the chronic form, occasion- 
ing the kind of hydrocephalus we have described, there is little more to be 
done than to attend to the general health of the child, and to endeavor to 
promote absorption of the fluid by the internal administration of diuretics, 
and the preparations of iodine. It has been proposed also to get rid of the 
fluid by tapping, as has been done in congenital hydrocephalus, and it is 



522 CHRONIC HYDROCEPHALUS. 

indeed in cases of the form we are now considering, when the fluid is en- 
tirely external to the brain, and where no malformation or organic dis- 
ease of the brain exists, that this operation has been found most successful. 
(See treatment of chronic hydrocephalus.) 



ARTICLE V. 

CHRONIC HYDROCEPHALUS. 

This term is applied to an affection characterized by an excessive accu- 
mulation of serous fluid, either within the ventricles of the brain or the sac 
of the arachnoid. 

The names internal and external have also been applied to it, in accord- 
ance with the position of the fluid : the former being given to those cases 
where the ventricles are the seat of the morbid collection, and the latter 
indicating that the fluid has accumulated in the cavity of the arachnoid 
and consequently surrounds the exterior of the brain. Chronic hydroce- 
phalus may either be congenital or acquired, the latter variety presenting 
the most interest in a practical point of view, since congenital hydrocepha- 
lus is usually associated with some malformation of the brain which renders 
extra-uterine life almost impossible. 

In either form it is a comparatively rare disease in Philadelphia. Our 
more recent experience however has furnished us with numerous oppor- 
tunities for studying its symptoms, treatment, and pathology. 

Morbid Appearances. — There are indeed few diseases in which it is 
of more importance to correctly establish the exact nature of the morbid 
process and the resulting lesions, since, as we shall see in a later part of 
this discussion, questions of the utmost practical value hinge upon the de- 
termination. 

Internal Hydrocephalus. — In this condition the amount of fluid is often 
very large, and varies from half a pint or a pint, to even as much as a 
gallon. Trousseau mentions a case where the fluid weighed 30 pounds, 
and Frank one in which it weighed 50 pounds. The formation of this ac- 
cumulation being gradual, the cavities of the brain accommodate them- 
selves to it, the ventricles become distended, and the communications be- 
tween their cavities are all enlarged; and occasionally the septum lucidum 
is perforated. This distension is usually most marked in the lateral ven- 
tricles. The hemispheres of the brain yield to the pressure of the increas- 
ing collection in the ventricles ; their convolutions are unfolded and flat- 
tened, so that the interval between them is only marked by a sinuous 
shallow groove, and the hemispheres are so thinned out as to form a layer 
not exceeding a few lines in thickness. It is not unusual, however, even 
when the distension of the brain has proceeded to this extreme degree, to 
be able to trace the cineritious and white layers, preserving their normal 
relations. The consistence of the expanded brain-substance varies in dif- 
ferent cases ; usually, however, it remains normal, or is even increased, 
though in some cases it has been found so soft as to tear upon the slightest 



ANATOMICAL APPEARANCES. 523 

traction. The structures at the base of the brain present the same changes 
in consistence. 

One of the most important questions in this rehition, as bearing upon 
the causation of the affection, concerns the condition of the lining mem- 
brane of the ventricles. 

The analogy of all other serous membranes would lead us to infer that 
in those cases where no mechanical obstruction to the circulation exists, 
such as a tubercular tumor pressing upon the sinuses of the brain, we 
should look for the cause of the serous accumulation in a morbid state of 
the lining membrane of the ventricles. This view is fully confirmed by 
the study of fatal cases of internal hydrocephalus, since in many cases this 
membrane is found much thickened, and either softened or roughened and 
granular. The granular condition of the membrane presents many degrees : 
in some cases it is merely a slight irregularity of the surface, while in others 
there is an unevenness as marked as that of shagreen, or even a formation 
of granules, which, at times, measure one-third of an inch in diameter, or 
even become distinctly pedunculated. 

Occasionally, a false membrane is found lining one or both ventricles, 
as the result of the chronic inflammation of the lining membrane of these 
cavities. 

Even when the symptoms of hydrocephalus have not appeared until some 
time after birth, the brain may be found to present positive evidences of 
congenital malformation, in the retarded development of some of the 
structures at its base. 

The veins of Gralen and sinuses of the dura mater are usually found 
in a healthy state, with their calibres quite free ; a fact which is of im- 
portance in considering the mode of production of internal hydrocephalus. 

In external hydrocephalus, the collection of fluid occurs in the sac of 
the arachnoid, or in a pseudo-cyst resulting from the transformation of a 
blood-clot, as described in our remarks on meningeal apoplexy : the brain 
is separated from the cranial vault and compressed against the base of the 
skull, as the lung is forced back against the spinal column by the fluid of 
hydrothorax. 

The superior cerebral veins, passing from the surface of the brain to the 
longitudinal sinus, traverse the fluid, and at times are so much stretched 
as to raise the surface of the brain into p<^)ints. 

Excepting in cases, however, where the disease is congenital and coinci- 
dent with some original malformation of the brain, there is no absolute 
diminution in the size of this organ. 

The character of the fluid varies considerably in different cases, and 
probably de|)ends to a great extent upon the cause. 

In an analysis by Spengler of the fluid evacuated in a case of hydro- 
cephalus by puncture, the fluid was clear and colorless ; specific gravity 
1010, of acid reaction, and contained no albumen. It also contained 
chlorides and phosphates of soda and jKitassa, but no sulphates. It ap- 
pears, therefore, in such cases as this, that the fluid is not the result of 
inflammation, but rather due to a passive dropsy. It is, we believe, espe- 
cially in cases of external hydrocephalus, where the fluid results from the 
transformation of a sanguineous efiusion, that it possesses these characters. 



524: • CHRONIC HYDROCEPHALUS. 

On the other hand, the fluid frequently contains a large amount of or- 
ganic matter, and closely resembles the effusion in pleurisy or pericarditis. 
Thus, in a case reported by Battersby, which was tapped eight times, the 
fluid always contained varying, and sometimes very large, proportions of 
albumen. 

Causes of Internal Hydroeephalus. — The opinions of the highest authori- 
ties and most experienced observers still difier widely upon this important 
point. 

We have alluded to the fact that not unfrequently the brain is found to 
present evidences of congenital malformation, and this fact has led to the 
opinion that internal hydrocephalus is almost invariably the effect of ar- 
rested development of the brain. 

Rilliet and Barthez place the eff'usion in this affection in the class of pas- 
sive dropsies, and express their belief that most frequently the cause of 
internal hydrocephalus is to be found in compression of the veins of Galen 
or ventricular veins, caused by the development of a tumor in the cranial 
cavity, and usually in the lobes of the cerebrum. 

The unfavorable influence which either of these views would have upon 
the prognosis and treatment of this disease, is of course evident. 

On the other hand, however, the opinion is advanced that the starting- 
point of internal hydrocephalus is, in fact, a morbid condition of the lining 
membrane of the ventricles. 

We have briefly described the appearances of this membrane which have 
now been observed in numerous well-authenticated cases of internal hydro- 
cephalus, and which plainly indicate the pre-existence of a chronic inflam- 
mation, so that we are led to believe that in a certain number of cases, at 
least, the effusion is due to a slow inflammatory action in the lining mem- 
brane of the ventricles. Those cases in w^hich these appearances have been 
found associated with retarded development of the brain, may be readily 
explained upon the supposition that the inflammation has been excited at 
a more or less advanced period of intra-uterine life, and that the resulting 
eff*usion has so compressed the structures at the base of the brain as to pre- 
vent their normal development. We may add that many eminent authori- 
ties, as Trousseau, now adhere to this view. 

In a very interesting case of this form which we have lately had under 
observation, the mother, a very intelligent and healthy woman, had quite 
a severe fall about the fourth month of pregnancy. In addition to this, 
however, she lost a favorite brother-in-law from a violent attack of cerebro- 
spinal meningitis about the same time. She nursed him constantly during 
his illness, and was very deeply impressed with the unnatural appearance 
of his face and head which had been shaved. This became so fixed an 
impression that more than once, between the time of his death and the 
birth of her child, she said it would not be strange if something were to 
prove wrong about the baby's head. We attributed the hydrocephalus 
which did actually develop in her infant to inflammatory changes, perhaps 
induced by the fall ; but the powerful maternal impression above men- 
tioned certainly constituted a curious coincidence. 

In cases, however, where the effusion into the ventricles depends upon the 



SYMPTOMS. 525 

development of a tumor in the cranial cavity, the growth ^Yill usually be 
found to occupy the cerebral lobes iu such a mauner as to compress the 
veins of Galen, which pass along the under surface of the corpus callosum, 
and are indeed the only true ventricular veins. 

The causes of extenialhydrocephahis are perhaps less obscure and uncer- 
tain than those of the internal form. 

In some cases, the effusion in the sac of the arachnoid is evidently 
due to a rupture of some portion of a brain distended by accumulation 
of fluid iu the ventricles, and hence is merely a sequel of internal hydro- 
cephalus. 

According to the able investigations of Legendre, and Rilliet and Bar- 
thez, one of the most frequent causes of external hydrocephalus is ha?mor- 
rhage into the arachnoid space ; the effused blood undergoing changes 
which result in the presence of large quantities of clear fluid, as described 
at length in our remarks on meningeal apoplexy. We have alluded to 
the fact that in many cases of external hydrocephalus the diminution in 
-ize of the brain is comparative rather than real; but there are instances 
where this form of the disease is found associated with malformation of 
the brain, which appears as a small, misshapen mass, pressed against the 
anterior part of the base of the skull. In such cases, it appears as though 
the fluid were ix)ured out to fill up the vacuum between the skull and 
atrophied brain. It is also possible that these conditions may be pro- 
duced by the occurrence of haemorrhage into the arachnoid space during 
intra-uteriue life, and before the brain had attained its normal develop- 
m'-iit. 

r^YMPTOMs; Physk AL Appearance. — The unusual size of the head is 
one of the most striking symptoms of hydrocephalus. In many cases 
associated with atrophy or retarded development of the bones of the face 
and the rest of the body, this enlargement appears even more monstrous 
than it in reality is. The diameters of the cranium are, however, very 
much enlarged; cases being on record in which at the age of a few weeks 
the circumference of the head has been twenty-three inches, or even 
more. 

The increase in the size of the head is not, however, invariably the 
earliest sign of the disease, being frequently preceded by marked symp- 
toms of nervous disturbance, or of impaired nutrition. 

The bones of the cranial vault which contribute to this enlargement are 
the frontal, the parietals, the occipital, and the squamous portions of the 
temporals. When the disease makes its a])pearance before the ossification 
of the sutures and fontanelles has been completed, the gradual increase of 
the fluid sejmrates these bones more and more widely. The occipital bone 
thus is pushed backwards, the parietals outwards and backwards, the fron- 
tal upwards and forwards. The increase in the size of the head is thus 
effected by the widening of the sagittal and coronal sutures, and by en- 
largement of the anterior fontanelle. 

The displacement of the frontal bone gives rise to a marked prominence 
of the forehead, which overhangs the diminutive features: while at the 
same time the pressure of the fluid depresses its orbital plate into an ob- 



526 CHRONIC HYDROCEPHALUS. 

lique position, contracts the orbital space, and gives rise to the character- 
istic appearance of the eye, the globe being prominent but directed down- 
wards so as to be buried beneath the lower eyelid, which conceals almost 
the entire cornea. 

The membrane which covers in the enlarged sutures is often distended 
and prominent, or remains on the normal level. A distinct sense of fluc- 
tuation is readily obtained by palpating one of these spaces, and in some 
cases, principally in young infants, and where the collection is very large, 
the head is absolutely translucent. When life is prolonged, and the dis- 
ease arrested, the ossification of the cranial vault is effected by the de- 
velopment of numerous supernumerary bones, or ossa triquetra, in the 
membranous spaces. These little bones are consequently found in the 
largest numbers in the coronal and sagittal sutures, where the deficiency 
is greatest and most wide. When, on the other hand, the disease does not 
begin until the sutures have united and the fontanelles ossified, it is rare 
for the head to attain any very large size. In a few cases, however, oc- 
curring in children of even nine years of age, the sutures have reopened 
under the continuous pressure, and the bones have been found separated 
as much as half an inch. 

More usually, however, in such cases, the pressure seems to expend 
itself in thinning the cranial bones, which become reduced to mere shells 
of light, fragile compact bone. Occasionally, so far from inducing thin- 
ning of the bones, actual hypertrophy occurs, and the bones of the cranial 
vault acquire an unusual thickness, and at the same time are dense and 
indurated. 

The early symptoms of the disease vary much. When it is congenital, 
there are nearly always evidences of cerebral disturbance either from the 
date of birth, or appearing within a few days. These symptoms are occa- 
sionally slight, consisting merely in an unnatural expression, with oscilla- 
tion of the eyes or strabismus : or, on the other hand, there may be attacks 
of convulsions frequently repeated. 

These symptoms speedily become associated with enlargement of the 
head and the characteristic alteration of physiognomy. When the dis- 
ease is strictly acquired, the early symptoms are even more varied. In 
one set of cases they are those of haemorrhage into the arachnoid ; in 
another the evidences of inflammation of the serous lining of the ven- 
tricles, of more or less acute character, are present ; whilst in numerous 
cases the only symptoms which precede the enlargement of the head are 
those of failing nutrition. 

Usually the aspect of children suffering with this affection is tranquil, 
or they may even present a certain unnatural gravity and apathy of ex- 
pression. 

Cerebral Symptoms. — At times the intelligence of the child, though per- 
haps poorly developed, remains intact, and there is no marked cerebral 
disturbance. 

In other cases, however, the advance of the disease is attended with a 
gradual failure of the intelligence, and impairment of the special senses, 
and especially of vision. 



DIAGNOSIS. 527 

In addition to the displacement of tlie globes of the eyes and alterations 
in the pupils already mentioned, the accumulation of fluid rapidly causes 
obstruction to the return of venous blood through the sinuses, so that even 
at an early stage, ophthalmoscopic examination shows marked changes in 
the fundus of the eyes. These consist in increase in the number and size 
of the veins of the retina, with later serous infiltration or even atrophy of 
the optic papilla. 

The nervous symptoms are at times much more marked ; and there may 
be frequently recurring convulsive attacks, or, as West mentions having 
seen in several cases, spasmodic attacks of difficult breathing, with a crow- 
ing sound in inspiration (^laryngismus stridulus). 

According to Rilliet and Barthez, the common sensibility of the sur- 
face is often impaired ; and there may be more or less complete paralysis, 
or contraction with rigidity of the extremities. 

It is, of course, difficult to estimate the amount of suflfering experienced 
by the little patients ; ordinarily it does not appear great, and indeed in 
-orae cases it has seemed chiefly due to the opposition offered by the cranial 
walls to the distension of the brain. 

In one case of MM. Rilliet and Barthez, the development of acute pain 
coincided with the ossification of the fontanelles. 

The general condition of children suflfering with chronic hydrocephalus 
varies greatly. 

In some cases they preserve their aj^petite and digestion, and appear 
well-nourished and strong to a late period in the attack ; but more fre- 
quently they present marked evidences of impairment of nutrition. 

The appetite may indeed remain, but the child loses both flesh and 
strength ; the bowels are irregular ; usually constipated, but alternating 
with temporary attacks of diarrhoea. 

In the majority of cases, perhaps, these symptoms are not sufficiently 
pronounced to establish the character of the attack, until the increasing 
-ize of the head becomes manifest, and the child acquires the distinctive 
physiognomy of hydrocephalus. Even after marked enlargement of the 
head has occurred, however, the advance of the case is far from being uni- 
In almost every instance there are pauses of the most variable 
: /lency and duration, during which the child seems free from pain, 
improves in general condition, and the development of the head is tem- 
porarily arrested. 

Death is frequently directly induced by .some intercurrent affection, 
wholly unconnected with the disease of the brain : while, in other case**, it 
immediately follows a violent attack of convulsions, or is preceded by 
.symptoms of an acute exacerbation of the cerebral di.sorder. In some 
rasf-s, also, the patient« sink into a condition of atrophy, and die worn out 
by the protracted suffering and malnutrition. 

DiAGNO*is. — During the early stage of the disorder, if the nervous 
symptoms are slight, consisting merely in occa-^ional attacks of heat of the 
head, attended with pupation or tension of the anterior fontanellf, and 
rf-tlessness, and crying, the diagnosis must remain uncertain. Art<'r the 
enlargement of the bead has progressed to any considerable degree, the 



528 CHRONIC HYDROCEPHALUS. 

expression of the little patient, taken in conjunction with the other symp- 
toms, is usually perfectly characteristic and conclusive. 

The morbid condition with which it is most likely to be confounded, is 
rickets of the skull. In fact, in some cases, the enlargement of the head, 
which results from these two affections, is quite identical. Usually, how- 
ever, this is not the case; and the hypertrophy of the rachitic bones takes 
place irregularly, so that the skull acquires a square instead of a rounded 
form ; the orbital plates of the frontal bones are not displaced ; so that, 
although the forehead may be large and overhanging, the axes of the eyes 
are not disturbed ; the fontanelles are not widely open, prominent, or dis- 
tended ; and, finally, of course, fluctuation on palpation is never present. 
In addition to this, the evidences of rickets in other portions of the body, 
and the peculiar symptoms of that affection, as detailed in the article de- 
voted to its consideration, nearly always enable the diagnosis to be readily 
made. 

We have already mentioned the changes which ophthalmoscopic exami- 
nation shows in the retina in this disease, and as a similar examination 
reveals no lesion whatever in cases of rachitic enlargement of the head, it 
is evident that the use of the ophthalmoscope may be of material aid in 
establishing the diagnosis between these affections, which is, despite all the 
points of distinction above referred to, obscure and difficult in some few 
cases. 

' In doubtful cases assistance may possibly also be derived from cerebral 
auscultation ; the presence of a bruit over the anterior fontanelle being 
thought by some authors to be a valuable indication of the rachitic nature 
of the enlargement of the skull. The significance of this cephalic bruit 
is, however, so much disputed, that it is at present impossible to assign any 
definite value to it. 

The only other pathological condition with which chronic hydrocepha- 
lus is apt to be confounded, is hypertrophy of the brain, an extremely 
rare affection, due to an increase of the interstitial connective tissue of the 
brain, the so-called neuroglia. 

In hypertrophy of .the brain, however, the symptoms do not usually ap- 
pear so early as in chronic hydrocephalus, nor is the cerebral disturbance 
so marked as in the latter affection. The enlargement of the head, also, 
which is the most characteristic feature of both conditions, is not so great 
in hypertrophy of the brain, and, instead of being uniform and assuming 
a rounded form as in hydrocephalus, occurs especially at the occiput. 
There is, further, no depression of the orbital plates of the frontal bones 
in hypertrophy of the brain, so that the axes of the eyes are not disturbed, 
and the globes are not displaced in the way we have already described as 
so characteristic of hydrocephalus. 

Finally, the sutures are not so widely open, nor the fontanelles tense 
and prominent as in hydrocephalus ; and, of course, the fluctuation which 
can be detected on palpation in some cases of this latter disease is never 
present. 

Prognosis. — Chronic hydrocephalus still ranks among the most fatal 
diseases ; so much so that Rilliet and Barthez — who, however, attribute 



TREATMENT. 529 

its production usually to the presence of a tumor in the brain — express 
their belief that it is invariably fatal. Indeed, it must be borne in mind 
that in many cases treatment must necessarily fail from the coexistence of 
some extensive congenital malformation of the brain. We should suspect 
the presence of this complication when there is serious disturbance of the 
nervous system, such as paralysis, or frequent and apparently causeless 
convulsions. Unfortunately, however, these hopeless cases cannot always 
be distinguished. 

While the prospect of a complete cure is very slight, it must be remem- 
bered that even a high degree of hydrocephalus is not incompatible with 
considerable prolongation of life. Thus cases have been known to attain 
the age of 15, 20 or even 25 years, with the maintenance of a fair degree 
of mental and bodily power. 

The prognosis in cases of external hydrocephalus, especially when of 
acute origin, is less unfavorable than when the effusion takes place into the 
ventricles. 

Whatever be the seat of the effusion, however, and the size of the head, 
the case must not be regarded as hopeless and beyond reach of remedial 
measures, so long as the functions of the brain are well performed, since 
there are well-authenticated cases of complete recovery from chronic hydro- 
cephalus, even when congenital. 

In a case we have recently had under observation, the symptoms of 
hydrocephalus, apparently of congenital origin, advanced rapidly up to 
the age of three and one-half years, at which the enlargement of the head 
was arrested, the mental and physical powers of the child developed reg- 
ularly, and at the age of seven years it seemed probable that complete 
recovery would result. 

Treatment. — It must be sufficiently evident, from the previous consid- 
eration of this affection, that there are numerous cases in which all treat- 
ment must prove unavailing, from the serious organic disease of the brain 
which accompanies it. Under any circumstances, however, the nature of 
the treatment and its efficiency will be much influenced by the early stage 
at which it is instituted. 

In regard to the utility of various sj)ecial remedies, also, there is the 
.Teatest diversity of opinion ; and, indeed, there is no plan of treatment 
vhich possesses so much evidence in its favor as that originally proposed 
by Profess^>r Golis, of Vienna. 

If the disease be in its incipience, and the constitution and hereditary 
tendencies of the child free from taint, this distinguished physician recom- 
mends that the head should be shaved, and one or two drachms of dilute 
mild mercurial ointment rubbed daily into ita scalp. While this treatment 
is being carried out, the head should be constantly protected by a flannel 
cap. At the same time, calomel should be given in doses of one-sixth to 
>ne-fourth gr. twice daily, unless it irritate the bowels, when the inunction 
alone should be continued. 

If after pursuing this treatment, conjoined with the most careful atten- 
tion to diet and all hygienic precautions, for five or six weeks, there is 



530 CHRONIC HYDROCEPHALUS. 

marked improvement in the condition of the child, the mercurials may be 
gradually discontinued. 

The iodide of potassium has been highly recommended as a substitute 
for the mercurials above mentioned, and several cases of apparent recovery 
under its use are on record. It should be given in large doses, and for a 
considerable length of time. Trousseau, who recommends its use, joins to 
its internal administration the external application to the head of lotions 
containing iodine. 

Should the disease remain uninfluenced at the end of this time, it is 
proper to add to the treatment diuretics and counter-irritants, in the form 
of issues in the back of the neck, which may be kept open for several 
weeks. Dr. West recommends the frequent application of blisters as a 
substitute for the use of issues. 

During the employment of this or any other mode of treatment, it will 
be occasionally necessary to have recourse to antiphlogistic remedies, to 
subdue the exacerbations of heat and restlessness which occur more or less 
frequently, and threaten the development of an acute inflammatory con- 
dition. Nor should we fail to pay attention to the proper performance of 
all the functions ; to the maintenance of the appetite and digestion by the 
use of tonics ; and in case of the existence of a scrofulous diathesis, to the 
administration of cod-liver oil, iodide of iron, etc. 

When, despite the most careful employment of well-directed measures, 
the disease is clearly advancing, it is worse than useless to persist in any 
plan of treatment which annoys or absolutely pains the doomed child ; our I 
only endeavor should then be to subdue any intercurrent disorder which! 
might hasten the fatal result. 

More than twenty-five years ago, the use of compression of the head, toj 
prevent its yielding to the accumulating fluid, was urged by Barnard, and 
experience has shown it to be a valuable adjunct to other treatment, though! 
it is inapplicable while any acute symptoms are present, and according tol 
West is best adapted to cases of external hydrocephalus succeeding to 
haemorrhage into the arachnoid space. 

M. Trousseau recommends the following mode of applying this pressure : 
Strips of adhesive plaster, about one-third inch wide, are passed from each 
mastoid process to the outer part of the orbit of the opposite side ; from 
the nape of the neck along the longitudinal sinus to the root of the nose ; 
across the whole head, intersecting at the vertex ; and finally are kept se- 
curely in position by a strip passed thrice around the head, the ends of the 
previous strips being turned up over the first coil of this strip, and secured 
by the succeeding turns. 

It becomes necessary to loosen these strips instantly, if any symptoms 
of compression of the brain develop themselves, since the increasing pres- 
sure of the accumulating fluid may produce irreparable injury to the base 
of the brain, or even, as happened to M. Trousseau, detach the ethmoidal 
bone from its connections. 

The unfavorable results of all strictly medicinal treatment, impelled 
physicians, at an early date, to resort to active surgical interference in 



Li 



TREATMENT. 531 

chronic hydrocephalus, by puncturing the cranium and evacuating the 
fluid. 

The operation should be performed with a delicate trocar and canula, 
the puncture being made in the coronal suture, about an inch or an inch 
and a half from the longitudinal sinus, — and in a majority of cases, no 
evil consequences appear to follow the operation itself Much difference 
of opinion still exists, however, as to its curative influence. From a rigid 
analysis of oG reported cases in which this operation had been performed, 
Dr. West came to the conclusion that in only 4 had a permanent cure been 
effected. Other successful cases have been since reported, so that the oper- 
ation must be recognized as at least a justifiable one in certain cases. 

The circumstances favorable to its performance are, when the hydro- 
cephalus is external ; or when internal, is due to previous inflammation of 
the lining membrane of the ventricles ; when there is no reason to believe 
that the disease is congenital, and attended with arrested development of 
the brain; when, though the head may be very large and increasing in 
size, the cerebral functions are not seriously impaired ; and, finally, when 
the nutrition of the child is still good. 

Until, however, the treatment previously recommended has been faith- 
fully tried, and unless the disease be evidently advancing, a resort to this 
operation would be incurring grave risks with but slight prospect of success. 

Brainard, of Chicago, has recently recommended the injection of solu- 
tions of iodine into the cranial cavity, after puncture and evacuation of 
the fluid. He has employed this in at least two cases, without the devel- 
opment of any severe symptoms as a direct consequence of the treatment. 

One of the cases died at the end of eight mouths ; the other, at the date 
of the report, only thirty-five days after the oj^eration, had shown no un- 
favorable symptoms. 

He advises the use of an aqueous solution of iodine, in the proportion 
(of one-third gr. with one gr. of iodide of potassium, to f.5j distilled water; 
of this from f5j to fsj, may be injected ; the strength of the solution and 
Xhf amount injected being increased at subsequent punctures. 

In one of his cases, twenty-one injections were practiced in the course 
of seven months. 

Injections of this strength are usually followed by no symptoms of in- 
flammation whatever ; and this exemption has led to the employment of 
much stronger solutions. 

Thus Dr. Tournesko of Bucharest Cquoted by Bouchut), injected f^iij 
tr. iorline in f^v distilled water, immediately after having drawn off by 
puncture f5xxiv of serum. The operation was followed by slight febrile 
eicitenient ; but, at the expiration of fifleen days, the child seemed in 
exeellent health, the circumference of the head having diminished from 
06 i to 43 centimetres. 



i 



532 ECLAMPSIA. 



ARTICLE VI. 

GENERAL CONVULSIONS, OR ECLAMPSIA. 

General Remarks. — The word convulsions is a generic term applied 
to different forms of spasmodic disease, very dissimilar from each other in 
many of their characters. 

Writers make different classifications of convulsions according to their 
peculiar notions in regard to the nature and causes of these disorders. 
The best division is, it seems to us, that adopted by most French writers, 
who arrange them by their supposed causes, making three classes, idio- 
pathic or essential, sympathetic, and symptomatic convulsions. The first two 
classes are unaccompanied by appreciable lesions of the nervous centres, 
while the third is called symptomatic, because it includes cases of convul- 
sions which are the sign or symptom of an appreciable lesion of the cerebro- 
spinal axis, as for instance, those which occur in the course of meningitis, 
tubercular disease, hydrocephalus, apoplexy, etc. In idiopathic or essen- 
tial convulsions, the cause of the attack acts directly upon the nervous 
centres, while in those to which the term sympathetic is applied, the cause 
lies in the influence or effect upon the brain or spinal marrow of disease of 
some other organ ; to the latter class belong the convulsions which occur 
in the course of pneumonia, bronchitis, the eruptive fevers, etc. 

We shall not pretend to give an accurate account of symptomatic con- 
vulsions in this article, as they have already been treated of under the 
head of the different organic diseases of the brain in the course of which 
they occur. We shall refer to them in the present article only so far as 
may be necessary to elucidate the pathology, diagnosis, prognosis, and 
treatment, of idiopathic and sympathetic convulsions. 

There is a form of eclampsia occurring in children, which we shall de- 
scribe separately, as it differs in many of its characters from ordinary con- 
vulsions. This is the disease known by the names of spasm of the glottis, 
thymic or Kopp's asthma, laryngismus stridulus, and eclampsia with suffo- 
cation. 

Definition; Synonyms; Frequency. — By the term convulsion is 
meant a paroxysm of variable duration, usually attended with unconsci- 
ousness, and followed by stupor, and characterized by a primary involun- 
tary tonic contraction followed by irregular clonic spasms of the affected 
muscles. 

In general convulsions, to which the above definition especially applies, 
the entire system of voluntary muscles is usually affected ; though, as will 
be described hereafter, the attack may be a complete and genuine one of 
eclampsia, and yet the convulsive movements be limited in their extent to 
a single group of muscles, or even a single muscle. 

The only synonyms which it is necessary to mention are epilepsia puer- 
ilis, insultus epilepticus, and eclampsia. The latter term, eclampsia, is, we 
believe, preferable to any other, and we would gladly introduce it instead 



CAUSES. 533 

of convulsions, which is too general a term to express the form of disease 
under consideration. 

The frequency of eclampsia is very great. During the two years 1873-74, 
1392 children under fifteen years of age died in this city of convulsions; 
whilst, during the same time, 1973 died of infantile cholera, and 893 of 
pneumonia. It must be recollected, however, that a very large number of 
these cases of eclampsia ought, beyond doubt, to have been returned under 
other titles, a:? manv of them must have been a mere result of organic dis- 
ease of the cerebro-spinal axis, or of other acute local or general diseases. 

Predisposixg Causp^. — Essential and sympathetic convulsions are 
much the most frequent before the age of seven years, which is the case 
also in regard to symptomatic convulsions, though the latter often occur 
after the age mentioned. We have ourselves met with not less than 200 
cases of convulsions, though we have preserved records of but 96. Of these, 
the age is noted in 91 cases, 19 of which occurred in the first year, 26 in 
the second, 20 in the third and fourth, 23 between the fourth and ninth, 
and 3 between the ninth and thirteenth years of life. Dr. West {op. ciL^ 
p. 42 I states that according to the Fifth and Eighth Reports of the Regis- 
trar-General, the deaths from diseases of the nervous system in London, 
under one year of age, bore a proportion of 30.5 per cent, to the deaths 
from all causes ; from the first to the third year, the proportion was 18.5 
per cent. ; from the third to the fifth year it was 17.6 per cent. ; from the 
fifth to the tenth year, it was 15.1 per cent. ; whilst from the tenth to the 
fifteenth year it was only 10.6 per cent., and the total above fifteen years 
was but 10.4 per cent. Again, to show the very great influence of age 
upon the predisposition to convulsions. Dr. West states that, within the 
first year, the deaths from convulsions constituted 73.3 per cent, of the 
total mortality from diseases of the nervous system ; between the first and 
third years, the proportional mortality from convulsions to the total mor- 
tality from aflTections of the nervous system, was 24.9 per cent.; between 
the third and fifth years, it was 17.8 per cent. ; between the fifth and tenth 
years, it was 9.9 |>er cent.; while between the tenth and fifteenth years it 
had fallen to 2.4 per cent. ; and above fifteen years it was but 0.8 per cent. 

It is jrenerally stated that convulsions are more common in girls than 
boys. MM. Rilliet and Barthez found this to be the case in their private 
practice, whilst in the hospital, .sympathetic and symptomatic convulsions 
were most frequent in boys. According to our experience, they have been 
alrooet efjually frequent in the two sexes, since of 92 cases that we have 
Been in which the sex was recorded, 47 occurred in boys and 40 in girls. 

It has been generally supposed that a delicate and nervous constitution 
is a powerful predisposing cause to convulsive attacks. Thid has been de- 
nied, however, by .several recent writers, whose observation is very careful 
and accurate. We are disp^>sed to believe that it is not so murh a feeble 
or delicate constitution that preflisposes to convulsions, as it is one charac- 
terized by a highly .«»u.sceptible, irritable, and nervous temperament, which 
often exi8t«t, in our opinion, in connection with a healthy and vigorous 
phy-ir-al organization. Of 96 children in whf)m we have seen convulsive 
attaf k-, and in whoni this point was noted, these occurred more than once 



534 ECLAMPSIA. 

in 13. Of the 13, nine presented every appearance of strong and vigorous 
health, with the exception that when laboring under any kind of sickness, 
as dentition, indigestion, the fever accompanying simple angina, in two the 
invasion of measles, and in one that of erysipelas, they immediately be- 
came extremely restless and irritable, or heavy and drowsy, and at a very 
early period, and sometimes with very little warning, were seized with con- 
vulsions. In one, a well-developed infant in its first year, the convulsions 
occurred every month or six weeks, without any appreciable cause. Three 
of the 13 were delicate : one was puny and feeble until after the comple- 
tion of the first dentition, when it grew strong and hearty ; one had had an 
apoplectic attack when an infant which had caused partial loss of power 
of one side ; and the third was very weak at birth, then grew stronger, and 
died in its second year of hydrocephalus following scarlet fever. The 
number of convulsions varied in the different subjects. In 1 there were 
five different attacks, in another four, in 4 there were three, and in 5, two. 
In two the attacks were very numerous, recurring frequently, and from 
very slight causes, or without any appreciable cause. They all recovered 
but two, and are still living. Of the 11 now living at various ages, all 
but one are free from anytl?ing like epilepsy, and that one, though liable 
during three years to attacks of an epileptiform character, became gradu- 
ally less and less subject to the seizures, and has now been for several years 
perfectly well in all respects. 

We have another patient, a boy, whose case is not included amongst the 
above, now five years old, who has had ten different attacks of convulsions. 
These attacks were all produced by some disturbance of his health. Sev- 
eral of them have occurred at the outset of a febrile reaction caused by a 
simple catarrh of the upper air-passages, — the convulsions ushering in the 
catarrh just as they sometimes do an attack of measles or scarlet fever. 
On other occasions, the seizure has evidently been the result of a febrile 
movement caused by indigestion or gastric irritation. After having had 
nine different attacks, he remained free from them for a whole year, and 
then had the tenth at the very beginning of a catarrh of the larynx, fauces, 
and nasal passages. This child has never as yet exhibited any symptom 
whatever of disease, either acute or chronic, of the cerebro-spinal axis, and 
as the convulsions have always been connected with a febrile movement, 
there is every reason to hope that they are not epileptic. Another patient, 
likewise not included amongst the above, a girl now five years old, has also 
had frequent attacks, but as they are of short duration, always coincident 
with the fever of catarrh, or digestive disorder, and on one occasion that of 
measles, and as between the seizures her health is excellent, there is but 
little reason to fear epilepsy. 

It is generally believed that the predisposition to convulsions is some- 
times hereditary. We have remarked in regard to this point, that several 
children in the same family sometimes suffer from the disease, and that the 
nervous temperament to which we alluded above, appeared in some in- 
stances to have been inherited by the child from its parents. 

In one family that we attend, out of six children, all but one have had 
attacks of convulsions : one of these children had but one attack, and that 



I 



CAUSES. 535 

was at the age of ten years, and was caused by a fit of indigestion occur- 
ring during convalescence from pneumonia. The other four children had 
each several attacks, occasioned always by the febrile movement result- 
ing from some of the numerous disorders of infancy. In none of these 
has there been any reason to suppose that the attacks were settling into 
epilepsy. 

Some very interesting evidence confirmatory of this view has recently 
been furnished by Dr. Robert P. Harris, of this city, in an article read 
before the Philadelphia Obstetrical Society (see Amer. Jour, of Obstet., vol. 
ii, No. 2, August, 1869). 

His record embraces 38 cases of eclampsia, 37 of which occurred in 13 
families, in which, collectively, there were 55 children who lived long 
enough after birth to prove their liability or exemption ; 4 having died 
too early to determine whether they were subject to convulsions or not. 

All of the individuals included in the statistics were descendants of the 
first, second, or third generations, of two pairs of ancestors ; of the pres- 
ent rising generation (the second) there are 31 members, only one of whom 
has as yet married ; twenty of the 31 have had convulsions. 

The exciting causers of convulsions are exceedingly numerous and dis- 
similar. Amongst the causes of essential convulsions are cited vivid moral 
emotions, violent pain, high temperature, exposure with the head uncov- 
ered to the sun, and sudden exposure to cold. In many cases, however, 
the exciting cause cannot be detected. The exciting causes of sympa- 
thetic convulsions may be almost any of the diseases incident to childhood. 
Amongst them we will cite as the most frequent, hooping-cough, pneu- 
monia, catarrh, scarlatina, measles, violent fever from any cause, dentition, 
and indigestion. 

It will be observed that many of the causes here assigned for convul- 
sions are also regarded as inducing cerebral congestion, either of the ac- 
tive or passive form. It is accordingly held by some authors that the 
way in which such influences act is to cause congestion, and that the con- 
dition of cerebral congestion is the cause of the convulsions. In our arti- 
cle on congestion of the brain will be found a brief statement of the 
considerations which lead us to doubt the propriety, in many cases, of as- 
cribing to that condition the convulsive and other nervous symptoms 
which occur so frequently in connection with the acute local or general 
diseases of childhood. In regard to some of the other causes above men- 
tioned, however, there can be no doubt that they are likely to induce 
extreme cerebral congestion. We have seen that in both the active and 
passive forms of such congestion, convulsions are of frequent occurrence. 
It is proper then to say that congestion of the brain, of either form 
and however produced, is among the frequent causes of eclampsia in chil- 
dren. 

Of 06 cases of convulsions, of which we have preserved notes, we havft 
regarded only 4 as essential, while 70 were sympathetic, and 22 sympto- 
matic. Of the 4 essential ca.ses, we could not detect the exciting cause in 
any. Of the 70 sympathetic ca,ses, it was scarlet fever in 12 ; pertussis in 
9; indigestion in 13; pneumonia in 3; the fever of simple angina in 6; 



536 ECLAMPSIA. 

cholera infantum and bronchitis, each 3 ; dysentery, 4 ; measles and den- 
tition, each 6 ; enteritis, the fever and irritation caused by a burn upon the 
back, and the onset of erysipelas, each 1 ; an o.verdose of castor oil (5vj) 
given to a young child with a slight cholera, 1 ; and lastly, fecal accumu- 
lations in the large intestine, 1. 

Symptoms. — Frodromic Symptoms. — It has been asserted by some writers 
that most attacks of convulsions in children are preceded by prodromic 
symptoms, which indicate to the experienced eye their approach. This 
does not agree exactly with our own experience, at least in regard to the 
essential and sympathetic forms, since of the cases of the former variety, 
well-marked prodromes did not occur in any, and of 64 cases of the latter, 
in which the early symptoms were noted, strongly-marked precursory phe- 
nomena occurred only in 8. We do not mean to say that there were no 
symptoms in the other 56 cases which might have indicated to an expe- 
rienced eye the probability of an approaching attack of convulsions, but 
merely that there were none that were strikingly characteristic, none 
which pointed out clearly and decisively that such a crisis was close at 
hand. In many of the 56, there were symptoms that might be regarded 
as indicating, with various degrees of probability, the approach of the 
convulsive seizure; but, inasmuch as they were such as constantly exist 
in children not predisposed by temperament or constitution to eclampsia, 
without the development of the disease, they scarcely deserve to be called 
precursory symptoms. 

The precursory symptoms of idiopathic and sympathetic convulsions 
are, therefore, difficult to describe because of their variable and uncertain 
character. They consist in general, however, of whatever indicates a 
highly disordered condition of the nervous system. The most marked 
symptoms are unusual drowsiness, excessive irritability, a peculiar physi- 
ognomical expression, general tremors, and the drawing of the thumbs into 
the palms of the hands, or rigid flexion of the toes. The drowsiness which 
precedes an attack of eclampsia, is almost always accompanied with some 
restlessness. The sleep is light and easily disturbed ; the child moves and 
turns, or starts and moans ; often it seems to have frightful dreams, and 
will scream out or wake suddenly bewildered and terrified, and when 
roused is generally exceedingly irritable, crying violently or fretting at 
the slightest contrariety, or without cause. The face, and particularly 
the eyes, often exhibit a peculiar expression, altogether diflTerent from 
their usual appearance. The expression which has most struck us, and 
which we have seen on several occasions, is a fixed and staring look, 
lasting but for an instant, as though the child were looking intently at 
some object, while in fact it is gazing at vacancy ; at the same time the 
fexpression is entirely without meaning. The child seems, in fact, for 
a moment, to be in a state of ecstasy. In some instances a sardonic 
•smile is seen to pass over the countenance just before the attack. The 
tremors or tremblings alluded to above, occur both in the sleeping and 
walking state, but particularly in the former. Flexion of the thumbs and 
toes has been noticed by different observers, but is, we believe, a sign 



SYMPTOMS. 537 

rather of the approach of symptomatic, than of essential or sympathetic 
convulsions. 

The precursory symptoms of symptomatic convulsions will depend on 
the nature of the disease in the course of which they occur. Not unfre- 
quently the convulsions occur at the very outset of the disease of the brain 
or spinal marrow, when of coui"se there will be no prodromic symptoms 
whatever. According to Dr. Marshall Hall (Diseases of the Xervoiis Sys- 
tem, p. 149 ), the first and most frequent sign showing that the excito-motory 
system is becoming complicated in diseases of the brain is vomiting, after 
which come strabismus, a contracted state of the muscles of the thumbs or 
fingers, or some unequivocal spasmodic or convulsive atiection of the re- 
spiratory muscles, or of the muscles of the limbs. 

Symptoms of the Attack: — "With or without the precursory symptoms just 
described, the convulsion itself usually begins suddenly. The child often 
utters a cry ; loses consciousness and is seized with powerful tonic contrac- 
tion of the voluntary muscles ; the eyes are for a moment fixed and staring, 
and then drawn obliquely upward under the upper lid, so that the white 
portions of the balls alone are visible for an instant between the partially 
open lids; the trunk is rigid and stiff, the thorax immovable, the respira- 
tion suspended by rigid spasm of the respiratory muscles ; the face, for a 
moment pale, usually becomes livid and congested, and the veins of the 
neck are distended. 

This state of tonic spasm is followed quickly by the stage of clonic 
spasm, in which involuntary and most irregular convulsive movements 
occur. The eyes are rarely fixed in one position, but are constantly agi- 
tated in various directions, from side to side, or upwards and downwards; 
very often there is the most violent strabismus ; the eyelids are sometimes 
open, at others shut ; the pupils may be contracted or dilated. The mus- 
cle-: of the face next enter into contraction, and occasion the most hideous 
contortions of the features. The mouth is distorted into various shapes, 
the lips are often covered with a whitish or sanguinolent froth, and the 
jaws tightly clinched together by tonic spasms, or agitated by convulsive 
movenienUs, so as to produce grinding of the teeth. The trunk of the 
body is also sometimes variously contorted by clonic convulsions. The 
head is usually strongly retracted upon the trunk, but in other instances 
is drawn to one side, or violently rotated. The muscles about the front of 
the neck enter into action, and alternately elevate and depress the larynx ; 
the tongue, when it can be seen, is observed to be moved in difll*rent direc- 
tions, and is sometimes caught between the teeth and severely bitten. The 
extremities, particularly the superior, are more violently convulsed than 
any other part«. The fingers are drawn into the palms of the hands, the 
forearms are flexed and extended upon the arms by short, rapid, and gen- 
erally rhythmical movement**, the hand is quickly pronated an«l supinated 
upon the arm, or finally the whole upper extremity is twisted and distorted 
into various positions, which it is impossible to describe. The inferior ex- 
tremities undergo similar movement*, but almost always in a less degree 
than the upper. The respiration during the attack is irregular, sometimes 
suspended by rigid spasm of the respiratory muscles, and sometimes accel- 



538 ECLAMPSIA. 

erated. A spasmodic contraction of the larynx, producing noisy inspira- 
tions, has been noticed by several writers. We shall find when we come 
to consider the nature of this disease, that Dr. Hall was of opinion that a 
more or less complete closure of the larynx is the most important feature 
of the convulsive crisis. The face is often livid and deeply congested, 
especially when the respiration is embarrassed ; the head is hot, whilst the 
extremities are cold; the pulse becomes large and full, or frequent and 
small, and sometimes cannot be counted in consequence of the contractions 
of the muscles of the forearm. The face is not always however congested. 
We have sometimes seen it perfectly white, while the convulsions were 
severe, and the child profoundly insensible. The action of the heart is 
tumultuous, and sometimes irregular or intermittent. When the attack 
is very violent, the urine and fseces are occasionally discharged involun- 
tarily, but these are rare symptoms. Deglutition is seldom impossible 
even in the severest fit. In severe, and especially in long-continued 
attacks, intellectual consciousness, and general and special sensibility, are 
all abolished. In milder cases, though consciousness is destroyed, some of 
the special senses still respond to irritants, whilst in still slighter cases, the 
intelligence also is more or less preserved. 

As the termination of the attack approaches, the convulsive movements 
become more and more feeble, until they finally cease entirely, and the 
child falls into a state of deep sleep, or of more or less profound stupor. 

Convulsions are not always, as we have just described them, general. 
They may be circumscribed or partial, aflTecting one side of the body more 
than the other, or one side alone, or a single arm, or in some cases, indeed, 
only a single muscle, as the biceps. Sometimes they implicate the eyes only. 
The inferior extremities are rarely afiected alone. Of the partial convul- 
sions the most frequent are those in which some parts of the face and 
upper extremities are attacked. In this form of the disease, the disorders 
of the circulation and respiration, the congested tint of the face, the froth 
upon the lips, and the derangements of intelligence and sensibility, are 
much less strongly marked than in general attacks. 

In still other cases, which have been by various authors grouped together 
under the objectionable title of " inward convulsions," the spasm affects 
chiefly the muscles of respiration ; at times being limited to the muscles 
of the larynx, and constituting the affection we shall describe in a special 
article under the name of laryngismus stridulus ; at others affecting prin- 
cipally the diaphragm and the thoracic and abdominal muscles of respira- 
tion. 

The duration of an attack of eclampsia concerns both the length of the 
convulsive crisis and the continuance of the disposition to renewals of the 
"crisis. Both of these are very uncertain. We have known the attack to 
last in all its violence eight hours and a half in one case, and twelve in 
another, and it is said to have lasted much longer in some instances. 
When the spasmodic movements continue during a long period, they are 
almost always interrupted by remissions. As a general rule, the duration 
is much shorter than the periods above mentioned, — from a few minutes 
to half an hour. When the attacks cease and recur, as they often do, 



II 
'I 



NATURE OF THE DISEASE. 539 

several times a day, thev leave the patient during the intervals in a state 
of more or less perfect consciousness or somnolence, restlessness or delirium, 
or finally of coma. The period durim; which the disposition to recurrence 
continues, depends principally upon the cause of the convulsions. If this 
continue in action, they will be apt to return until it is removed. 

Idiopathic and sympathetic convulsions generally consist of a single 
attack, though there are sometimes several, which occur at intervals of 
«ome hours, or of one or two days. Sympathetic convulsions usually occur 
cither at the beginning or termination of the disease which they compli- 
cate, and much less frequently during its middle period. Of 40 cases of 
this form observed by ourselves, complicating measles, scarlet fever, ery- 
sipelas, pneumonia, bronchitis, cholera infantum, simple angina, and dys- 
entery, in which the period was carefully ascertained, they occurred at 
the invasion alone in 25, at the termination alone in 15, at the middle 
period alone in 3, and at the invasion and termination both in 3. It is 
curious to remark, that of the 25 cases that occurred only at the invasion 
of the disease, all but 7 recovered ; that the 3 occurring in the middle 
period alone, also recovered ; that of the 3 occurring both at the invasion 
and termination, 2 died ; and that all of those which occurred at the ter- 
mination alone, proved fatal. 

MM. Rilliet and Barthez state that half the cases of symptomatic con- 
vulsions observed by them, occurred at the commencement of the ence- 
phalic disease. This form seldom consists of a single crisis ; the attacks, 
on the contrary, are repeated from time to time. The authors just quoted 
state that whenever the convulsive attacks have recurred repeatedly within 
a period of a few days, they have proved symptomatic of disease of the 
brain. 

Nature of the Disease. — One of the most important contributions 
which has been made towards a plausible and satisfactory explanation of 
the pathology of convulsions in children, was afforded us in the writings 
of Dr. Marshall Hall ; and, although more advanced knowledge of the 
physiology of the nervous system has shown that the part of the cerebro- 
spinal axis involved in the production of convulsions is not limited, as he 
supposed, to the b-ue spinal system, his theory of excito-motor action fur- 
nishes the most ready explanation of very many ca.«es of eclampsia. Dr. 
Flail says (Diseases and Derangements of the Nervous System, p. 145) : 
"That the whole class of convulsive diseases consists of affections of the 
true spinal system, there is no longer any doubt. But these diseases do 
not all originate in this system." All convulsive disorders are, according 
to this dfK-trine, affections of the tnie spinal or excito-motory system. 
The causes of these di.sorders may be of incident origin, acting upon 
excitor nerves; of centric origin, seatefl in the brain or spinal marrow; 
or of reflex origin, acting upon reflex or motor nerves. They are called, 
therefore, according to their causes, central or centric, when they depend 
on disease of the nervous centres; centrifxjtal when they are excitrd 
through excitor nerves; and centrifugal when they depend on disease of 
the motor nerves. 

Dr. Hall, as is well-known, ascribed great importance to the condition 



540 ECLAMPSIA. 

of the glottis in convulsions. He says (p. 323), in speaking of epilepsy, 
" The second symptom is a forcible closure of the laryrix and expiratory 
efforts, which suffuse the countenance and probably congest the brain with 
venous blood." At page 327, he says: "A spasmodic affection of the 
larynx has obviously much to do in this disease (epilepsy), as well as in 
the crowing inspiration or croup-like convulsion of infants ; so much, in- 
deed, that I doubt whether convulsion would occur without closure of this 
organ." In describing the croup-like convulsion or laryngismus stridulus 
(p. 180), he says : " I must repeat the observation that the respiration is 
actually arrested by the closure of the larynx ; and there are forcible ex- 
piratory efforts only or principally in the actual convulsion." In a later 
publication, Dr. Hall says: "Without closure of the larynx, extreme 
laryngismus, and the consequent congestion of the nervous centres, there 
could, I believe, be no convulsion ! This closure of the larynx must be 
complete in the affection under consideration (laryngismus stridulus), as 
in all others, before convulsions can take place." (^Braith. Ret. from Lancet, 
June 12th, 1847, p. 609.) 

It is, however, evident that the obstruction to respiration exists not 
only in the larynx, but in the thorax, the muscles of which are rigidly 
contracted. Nor can we at present admit that this spasm of the muscles 
of respiration is more than coincident with the other phenomena of the 
convulsive attack : and, indeed, there are reasons for believing that the 
accumulation of venous blood in. the nervous centres which follows the ob- 
struction of respiration, so far from causing the convulsion, has a tendency 
to arrest it, and to induce a state of coma. 

It is, however, easy to comprehend the mode of production of sympa- 
thetic convulsions by reference to these doctrines. They evidently depend 
upon morbid impressions conveyed to the cerebro-spinal axis through the 
exciter nerves having their origin in the diseased organs, probably con- 
joined with a state of undue reflex excitability of certain parts of the 
nervous centres. Thus it is easy to understand why inflammation of the 
parenchyma of the lung in pneumonia, of the bronchial mucous mem- 
brane in bronchitis, of the mucous membrane of the bowel in entero-colitis 
or dysentery, or the pharynx in angina ; why the pressure of a tooth upon 
an inflamed gum during .dentition, the presence of a foreign body, as news- 
paper (in one of our own cases), or crude food, in the stomach, or fecal, or 
lienteric accumulations in the intestine, should produce a degree of irrita- 
tion in exciter nerves, sufficient, when transmitted to the sensori-motor 
ganglia, to occasion the convulsions we have been considering. 

It is more difficult to explain the mode in which continued fevers, mea- 
sles, scarlatina, etc., give rise tq convulsions. To us, however, their occur- 
rence is explicable by the morbid effect produced upon the nervous centres 
by the blood, which is known to be more or less changed in these affections 
from its healthful condition, and also by the mere fact of the existence 
of fever ; for we have met with a number of children in our own practice, 
who are almost certain to have a convulsive seizure, whenever the circula- 
tion becomes greatly excited in force and frequency by the existence of 
fever, no matter what be its cause. 



DIAGNOSIS. 541 

The explauatiou of the production of idiopathic or essential convulsions 
is not always so easy, because we are sometimes unable to detect any cause, 
either centric, centripetal, or centrifugal, to account for the excitation of 
the nervous system. It seems probable, however, that they must depend, 
like those of the sympathetic form, upon some unhealthful, and therefore 
irritating condition, acting upon the excito-motory system of nerves. The 
cause may be so slight as to escape the notice of the physician, and yet 
>ufficient to produce a convulsive crisis in a child predisposed to eclampsia. 
It may be an unnoticed dentition, some undigested food in contact with 
the stomach or intestines, or accumulations of unhealthy fecal substances, 
or of vitiated secretions, in the intestines. When convulsions have fol- 
lowed a vivid mental emotion, as passion or vexation, they are evidently 
a result of the influence of that condition upon the nervous centres. 
Acute pain, which is said to have occasioned essential eclampsia, as well 
as exposure to violent heat or severe cold, must produce their effects 
through their action upon incident excitor nerves. There is also in all 
}>robability, in most children who suffer with convulsion, a state of preter- 
natural mobility and increased reflex excitability of certain parts of the 
cerebro-spinal axis, which predisposes to disorderly nervous action, even 
upon trifling causes. There can be no doubt that this irritability of the 
nervous system is frequently inherited, though it may be acquired in the 
course of chronic debilitating diseases. Although we have described these 
convulsions under the title of essential and sympathetic, we do not mean 
to assert that they are absolutely independent of any material changes in 
the nervous centres, but merely that, up to the present time, no appre- 
ciable lesions have been detected as their causes. It is indeed true that, 
in a certain number of instances, after death from eclampsia, there are 
found eugorgement of the vessels of the membranes and of the substance 
•jf the brain, serous effusion into the cavity of the arachnoid or the lateral 
ventricles, or even actual cerebral haemorrhage. In a certain proportion 
of cases, undoubtedly, cerebral congestion acts as the direct cause of 
eclami)sia, a.s we have stated in our article on the former subject. But 
in the majority of cases, the lesions above mentioned cannot be considered 
as the caiLses of the convulsive attack, but on the other hand must be re- 
garded as the direct result of the convulsion, and due to the intense vas- 
'ular engorgement caused by the spasm of the resj)iratory muscles and 
the consequent arrest of the venous circulation. And indeed it is the 
danger of the occurrence of such lesions which imparts much of the grav- 
ity to the prognosis in all severe attacks of eclampsia in young children. 

All symptomatic convulsions belong, of course, to the class of centric 
diseases. These need no further remarks. 

Diagnosis. — There arc two important points to be considered in treat- 
ing of the diagnosis of eclam|>sia : the diseases with which it may be con- 
? 'in-led, and the causes which may have produced the convulsions, or, in 
other words, their distinction into essential, symjiathetic, and symptomatic. 

The only disease with which eclampsia is likely to be confounded, is 
f nilf'psy ; the mistake could only be made when the former is violent, and 
v;.» n it is accompanied and followed by unconsciousness. In epilej)sy, 



542 ECLAMPSIA. 

however, the invasion is more sudden, the convulsions are accompanied 
with greater rigidity, there is always frothing at the mouth, the duration 
of the crisis is shorter, and it is generally followed by more marked stupor. 
If the convulsive attack have occurred under the influence of an appreci- 
able cause, if the parents are not epileptic, and if the child is very im- 
pressionable, it is probably eclampsia. Again, the younger the patient, 
the more likely is the case to be one of eclampsia; whilst if the child is 
approaching towards puberty, if the attacks are frequently repeated, and 
yet not dependent on fever, and if they are followed by complete restora- 
tion to health in the interval, the disease is much more likely to be epilepsy. 

The diagnosis of the form of the attack, whether idiopathic, sympathetic, 
or symptomatic, is exceedingly important, as upon this must depend in 
great measure the prognosis and treatment. It is often very difficult, and 
sometimes impossible, to determine at the moment to which class the con- 
vulsions belong. The most difficult points in the diagnosis are the follow- 
ing : first, when a child previously in good health, is suddenly seized with 
the disease, to determine whether it is essential ; whether it is sympathetic 
and occasioned by disease which, up to this instant, has been latent, or 
by the invasion of some one of the acute local diseases, or of one of the 
continued fevers; or lastly, whether it is symptomatic, marking the in- 
vasion of a disease of the cerebro-spinal axis : second, when the convulsion 
occurs in the course of a disease not primarily implicating the nervous 
centres, to determine whether it is merely sympathetic of that disease, or 
whether it is symptomatic of an intercurrent affection of the brain or spinal 
marrow. 

It is impossible for want of space, to treat of all these points in detail. 
The enumeration of them, however, will be useful in calling the attention 
of the reader to their importance. 

An essential convulsion is only to be distinguished by careful study of 
the antecedent history and present condition of the patient. If, after a 
thorough examination of all the organs, no diseased point can be detected, 
and if the child recover perfectly from the convulsion, we must conclude 
that the case has been an idiopathic one, in which the cause is beyond our 
reach. We are disposed to believe, however, as has already been stated, 
that in most such cases there has been a source of irritation in some of the 
organs of the body, which has acted as the excitant to the excito-motory 
system, and which, if we could but detect it, would warrant us in classing 
the case amongst sympathetic convulsions ; and on this account a search- 
ing physical examination should be made in every case, as a matter of 
course. 

The sympathetic and symptomatic forms of eclampsia are to be diag- 
nosticated by the same careful attention to the antecedent history and 
present condition of the child. If the latter is teething at the time of the 
fit, and there is no other cause to explain the attack, and should there be 
nothing in the consecutive symptoms to render such an explanation inad- 
missible, we may refer it to that condition. We may remark merely, that, 
as a general rule, eclampsia depending entirely upon the irritation of den- 
tition, is seldom either violent or long-continued, and that the return to 



PROGNOSIS. 543 

consciousness and health is speedy. The probable dependence of the attack 
upon indigestion is to be ascertained by the absence of other causes, and 
by our learning upon inquiry that the child had eaten of some indigestible 
substance within a few hours or a day or two before the attack. Its de- 
pendence on intestinal accumulations is to be arrived at by the same neg- 
ative or exclusive method, and by learning that the patient is usually, or 
has been of late, of a constipated habit. 

When the attack occurs in the course of some other disease, as pneu- 
monia, catarrh, enteritis, pertussis, scarlatina, or measles, it is almost 
certainly sympathetic. It may possibly, however, be indicative of an in- 
tercurrent attack of cerebral disease. This can be determined only by 
attention to the consecutive phenomena. If the attack be short, and soon 
followed by complete restoration to consciousness, it is in all probability 
sympathetic. If, on the contrary, the convulsive crisis be long and se- 
vere, if the recovery from it be slow and imperfect, if it be followed by 
violent agitation, somnolence, or coma, or by some persistent lesion of mo- 
tility, there is every reason to fear an attack of disease of the brain. 

iSympathetic convulsions, occurring at the invasion of different local or 
general diseases, are to be distinguished only by observation of the symp- 
toms that follow the crisis, which will be those belonging to the particular 
malady whose approach has caused the attack of eclampsia. 

Symptomatic eclampsia is characterized by various signs of encephalic 
disorder, which soon follow the convulsive attack. The most important 
of the^e are severe and continued headache; diminution or exaltation of 
general or special sensibility ; dilatation or contraction of the pupils ; ir- 
regular movements of the eyes ; flexion or stiffness of some of the limbs, or 
of the fingers or thumbs; disordered intelligence ; or the symptoms which 
have already been described in the articles upon the diseases of the brain. 

Prognosis. — The prognosis of essential convulsions must depend on the 
nature of the cause and the violence of the attack. When the cause has 
been slight, or one which soon ceases to act, or can be readily removed, the 
prognosis is much more favorable than under opposite conditions. If the 
convulsive crisis is short and of moderate severity, if the pulse and respi- 
ration are but slightly disturbed, if there be but little congestion of the 
face, and no stertor, there is every reason to hope a successful issue in the 
case. Of the three cases of thia class that we have seen, two recovered 
and one died. 

Sympathetic is more dangerous than es-sential eclampsia, but much less 
so than symptomatic. The prognosis will depend chiefly on the nature of 
the diseaiKJ which it complicates, and on the stage of that disease at which 
it occurs. Thus, in scarlatina, convulsions, especially when they occur in 
the first few days of the disease, are almost always fatal, in measles much 
less so, and in other diseases in various proportions. They are very apt to 
terminate unfavorably when they occur after the malady which they com- 
plicate has been in progress for several days. This is a renuirk made 
by various authors, and we have already stated that of 46 cases of this 
form in which we carefully ascertained the period of their occurrence, 25 
ap{)eared at the invasion, of which all but 7 ended favorably ; .'i at the 



544 ECLAMPSIA. 

middle period, which all recovered ; 3 both at the invasion and at a later 
period, 2 of which were fatal ; and 15 after the cases had been progressing 
for a considerable time, all of which proved fatal. In addition to these 
important elements for making the prognosis, we must consider, also, the 
duration and degree of violence of the paroxysm, the state of the patient 
after the fit as to its cerebro-spinal functions, and lastly the age and con- 
stitution of the child. 

The prognosis of symptomatic convulsions must depend very much upon 
that of the disease of which they are the symptom. It may be stated, as 
a general rule, that, like those of the sympathetic class, they are less dan- 
gerous when they occur at the beginning than at a later period of the dis- 
ease. They are always, however, very dangerous. Of 22 cases that we 
have seen, 19 were fatal. 

It frequently happens, however, that although life is not destroyed by 
the convulsions, certain grave sequelae remain, among which the most fre- 
quent are paralysis, disorders of the mind, and defects of speech or vision. 
These symptoms are, it is true, far most frequent in cases of symptomatic 
convulsions, where they depend upon the same lesion of the brain which 
occasioned the fit. They may, however, succeed convulsions which we are 
still obliged to call essential, although there very possibly is some minute 
alteration or defect in a part of the nervous centres, which our means of 
observation do not suffice to detect. In such cases these sequel se probably 
depend upon some lesion of the brain, such as cerebral haemorrhage, which 
has occurred as a result of the convulsion. 

Hemiplegia, which is the form of paralysis which most frequently follows 
eclampsia, is most apt to occur when the fit has been limited to one side 
of the body ; it is often temporary, and passes away in a few days, though 
it may reniain persistently. Dr. J. Hughlings Jackson suggests that, in 
the absence of evident disease in such cases of unilateral convulsion and 
palsy in children, the symptoms may depend upon the plugging of very 
small vessels in the brain. 

Treatment. — We shall copfine our remarks upon the treatment of 
eclampsia to the essential and sympathetic forms of the disease, having 
already treated of that of the symptomatic form in the articles upon the 
cerebral diseases which give rise to it. 

We think that the treatment of eclampsia in children may be simplified 
if we pay attention to two distinct conditions of disorder, which appear to 
exist in every case. These are the condition of morbid irritation or de- 
rangement of the excito-motory system of nerves, and the cause which oc- 
casions that derangement. The condition of irritation or disease of the 
cerebro-spinal axis exists in all cases, and is always the same, diflTering 
only in degree and extent ; whilst the morbid cause of that irritation differs 
in each case, being in one dentition, in another pain, in another constipa- 
tion, in others pneumonia or indigestion, pleurisy, catarrh, or angina, scar- 
let fever, measles, fright, or other violent emotions. If this view of the 
subject be correct, it is clear that in treating a case of convulsions we have 
to attend to the two morbid conditions referred to, and we shall be care- 
ful, therefore, in the course of our remarks, to treat of the remedies most 



TREATMENT. . 545 

proper for the removal of the cause, whatever it may be, wliich acts a? the 
irritant to the nervous centres; and of those calculated to subdue or allay 
the deranged condition of those centres and the effects of that derange- 
ment. 

There are some general rules to be followed in the treatment of convul- 
sions which apply to all cases, and of these we shall tirst speak. They are, 
to place the child in a large urll-vcnfilated room, if such can be procured ; 
if it have been seized in a little close room, where the atmosphere is dense 
and impure, removal to another room, or exposure to fresh air before an 
open window, has sometimes sufficed to terminate the crisis. At the same 
time the clothes of the child should be loosened, in order to prevent all 
constriction, and, if necessary, taken off, to allow of a careful examination 
of the whole body. We believe it is a good rule always to place the child, 
DO matter what be the cause of the convulsion, if it be a severe one, in a 
mrm-bath (OG^ or 97^ F.). This has frequently proved an efficient remedy, 
according to our experience. It is easily procured in most cases, and we 
are quite confident that we have never known it to do harm, though we 
have used it in almost every case. The patient should be kept in the bath 
-ome ten, fifteen, or twenty minutes, or until the convulsive movements 
cease; when taken out it is most convenient, and at the same time useful, 
to envelop it in a small, light blanket, or flannel, for a short time, before 
the clothes are readjusted. 

In cases where the attack of eclampsia is limited to a single convulsive 
seizure, we rarely have an opportunity of instituting any treatment for the 
paroxysm itself, since it is usually over before we reach the patient. In 
- 'i instances, bloodletting is unnecessary. If, however, the opportunity 
-, and if the convulsion occur in a strong and vigorous subject; if it 
be violent, and accompanied by a deep red, or yet more by a livid flush of 
the face, and distension of the veins of the head and neck ; if it last more 
than a few minutes, or is re^jeated after short intervals of quiet, we would, 
without hesitation, recommend the use of hloodiettlng. The detraction 
of blood is called for, in our opinion, for the same reasons as in puer- 
peral convulsions, and indeed in every violent convulsive attack, — to 
save the nervous centres from the effects of the paroxysm, which are, in 
all severe cases, excessive congestion, and, in some, fatal effusions. There 
are, however, many cases, in which we would not advise depletion ; as, for 
instance, those in which the convulsion depends upon an auajmic con- 
dition, and in which it is contraindicated by a naturally feeble, or by a 
']^ ilitated state of the constitution; those in which it is clearly unneces- 
sary, from the slight severity or short duration of the attack; or those 
which occur in the course of other diseases, and particularly at their ter- 
mination, and in which a resort to it is rendered evidently improper by 
the circumstances of the concomitant afiection. The quantity of blood to 
be taken, and the method, must depend on the circumstances of the case. 
W.' must be guided as U) the quantity by the age and constitution of the 
; .' nt, the violence and duration of the paroxysm, and the cause of the 
attack. In a strong, hearty child, two or three years of age, in whom the 
attack is violent, and produced by some cause not likely to continue long 

35 



546 . ECLAMPSIA. 

in action and thereby exhaust the strength, we may take from two to four 
ounces at the first bleeding ; and should this fail to exert an influence 
upon the paroxysm, a rather smaller quantity may be taken in one or two 
hours afterwards. In younger children, and those who are somewhat 
feeble or delicate, the amount drawn ought to be less. Usually speaking, 
venesection is to be preferred ; but when a general bleeding cannot, from 
any cause, be employed, we may resort to cups and leeches to the temples 
or back of the neck, or, as advised by some of the French writers, to more 
distant parts. 

We believe it is useful in all cases of essential and sympathetic convul- 
sions, which resist the employment of a warm bath and bleeding, and also 
when bleeding is not resorted to, to make use of an emetic of some kind. 
The act of vomiting alone is often sufficient to break up a paroxysm of 
convulsions which has resisted various other means. This we learned first 
from the advice of an old and experienced practitioner, who was in the 
habit of employing emetics in all cases of eclampsia of children, and we 
have since seen it tested on numerous occasions. Dr. Hall recommends 
the induction of vomiting in the treatment of the paroxysm of the croup- 
like convulsion or laryngismus stridulus, and as a means of prevention in 
epilepsy. In the former he employs irritation of the fauces by tickling 
with a feather ; in the latter, ipecacuanha. He says that a new mode of 
action is induced in the true spinal system by the act of vomiting, so that 
the disposition to closure of the larynx, and expiratory efforts, is exchanged 
for sudden acts of inspiration. The emetic which we employ is ipecacu- 
anha. The employment of emetics is generally advisable, even when 
there is no evidence that the attack is due to the presence of undigested or 
irritating substances in the stomach, since in cases of sudden eclampsia 
the cause is so frequently some gastric irritation. Of course, when there 
is special reason to suspect the presence of such a condition, the indication 
for the administration of an emetic is even more positive. 

in addition to warm baths, bleeding, and emetics, cold applications to 
the head will be found proper and useful in nearly all cases which are of 
any considerable violence. Their use would be improper, however, when 
the surface is pale, the features contracted, and the pulse small and feeble ; 
.but whenever the skin, especially that of the head, is deeply colored and 
turgid, and the pulse full and strong, they ought to be employed from the 
beginning. While the child is in the bath, its head may be wrapped in a 
cloth wet with ice-water ; or, after it has been removed, cold water may be 
poured from pitchers or a tea kettle upon the same part. If the latter is 
done, enough should be employed to prevent the sudden reaction which 
inevitably takes place when but a small quantity is used. During the 
after-treatment of the case, the cold applications ought to be continued so 
long as the head remains unnaturally heated. 

The administration of a purgative dose is proper and useful in most 
cases of convulsions; particularly when it is found upon inquiry that the 
child has been constipated prior to the attack; when it is suspected that 
.the bowels may contain crude food or some foreign body ; when it is de- 
sirable to produce an evacuant effect in a strong plethoric child, or a 



TREATMENT. 547 

derivative action from the brain, and wlien the attack is attended with 
violent determination of blood towards that organ. The best purgative in 
severe cases occurring in hearty children is calomel. It is advantageous 
because of its e^sy administration, its speedy operation, and the powerful 
sedative influence which it exerts upon the whole economy. The dose 
should be from three to six grains, according to the age. It ought to be 
followed in one or two houi-s by some other cathartic, which may be either 
castor oil, rhubarb, jalap, or salts. The best of all is castor oil if it can 
be given. When the attack is slight or the patient weak and delicate, cas- 
tor oil is particularly applicable, as it operates with so little irritation to 
the intestine, or we may employ a mixture of castor oil and spiced syrup 
of rhubarb. Whatever the remedy may be, it should be given only in 
such quantity as to produce complete evacuation of the bowels and a 
moderate derivation upon those organs, without the risk of occasioning a 
degree of irritation sufficient to increase the disturbance of the nervous 
system already existing. 

In many, indeed, in most cases of eclampsia it will be found that purga- 
tive enemata are of great service. They may be administered immediately 
before or after the bath, and not unfrequently have the etlect of stop})ing 
the paroxysm. They may consist of water holding in suspension or solu- 
tion castile soap, common salt, molasses, castor oil, sweet oil, or spirit of 
tur[)entine. If the fii-st fails to operate in ten or fifteen minutes, another 
or even a third ought to be given. 

Bevul^ives are of the utmost importance in the treatment of convulsions. 
They should be employed from the very first, or immediately after the use 
of the bath. In slight attacks, they alone are often sufiicient to suspend 
the paroxysm, or at least the fit often ceases under their use. Mustard is 
the most useful and convenient form of application in the great majority 
of cases. It may be used either in the form of sinapisms, which are to be 
-hifted from place to place, or in that of the foot-bath. When sinapisms 
are used, they should always be covered with gauze or fine muslin, to avoid 
the danger of leaving any of the mustard upon the skin after they are taken 
off. We once saw very bad ulcerations upon the feet of a child from the 
II' L'lf'ct of this precaution. In the hurry and bustle of the moment, the 
1- . ; were not washed when the plasters were removed, and the mustard 
that remained produced vesications which ulcerated. In obstinate attacks, 
the revulsives ought to be reapplied from time to time, taking care to shift 
their position in order to avoid vesication. 

Antispasmodics are very valuable remedies in eclampsia, but as they are 
somewhat slow in acting, we should first resort to the means already de- 
tailed. We should then give full doses of one of the antispasmodics 
r mmended below, and should continue its use so long as may bo 
i; i^'ht desirable after the attack has passed over. They should also 
be used as a means of prevention in children threatened with eclampsia. 

The bromides of potassium and of so<lium are the most powerful and 
reliable remedies of this class in the treatment of almost all forms of 
coDTulsioD in children. They may be given in the dose of three to five 



548 ECLAMPSIA. 

grains, three or four times a day, from the age of six months to one year, 
with an additional grain for every year. 

Next to the bromides, the ones most highly recommended are valerian, 
oxide of zinc, assafoetida, and camphor. Of these, valerian or assafoetida 
are the ones we have usually employed. Valerian is best given in the form 
of the fluid extract, of which froui ten to twenty drops may be administered 
in Avater, to a child two years old, every half hour or hour, until several 
doses have been exhibited, after which it ought to be suspended for awhile 
or given in smaller quantity. Assafoetida is best given in the form of emul- 
sion, half a teaspoonful being administered by the mouth, or one or two 
teaspoonfuls mixed with a little warm water may be thrown from time to 
time into the rectum. M. Brachet {Traite Prat, des Convulsions dans 
VEnfance, 2eme ed., pp. 102-3) highly recommends the oxide of zinc in 
combination with extract of hyoscyamus, to the amount of at least two 
grains of the former and four of the latter in twenty-four hours, divided 
into four, eight, or twelve doses. A dose was given every two or three 
hours, and when the symptoms were very violent, the first two or three 
were repeated at much shorter intervals. 

Opium is a remedy which requires much care and discrimination in its 
employment, but which, in certain conditions of the disease, is of the great- 
est service. It should not generally be given while there remains any 
evidences of considerable determination of blood to the brain, but when 
this condition does not exist, or after it has been removed by bloodletting 
and revulsives, opium proves very useful in allaying irritability and rest- 
lessness, which themselves seem to keep up a disposition to a return or con- 
tinuance of the convulsive phenomena. Somnolence also, and still more, 
coma, likewise contraindicate the use of opium. Dr. Eberle thinks he has 
seen much advantage from frictions over the spinal region with a mixture 
of equal parts of oil of amber, laudanum, and spirit of camphor, particu- 
larly in very young infants. 

Chloroform has been highly recommended in the essential convulsions of 
children, by Sir J. Y. Simpson {Edin. Med. Jour., June, 1858), and is 
favorably spoken of by both West and Trousseau. It should be used 
when the fits are violent and recur frequently, and do not yield to any of 
the remedies previously mentioned. By careful administration, anaesthesia 
may be prolonged for many hours, though, as Simpson recommends, it 
should be allowed to partially pass ofi* every two or three hours for the 
purpose of feeding the child. It has been employed in numerous cases 
with the effect of arresting the convulsions, and in no instance has any 
unfavorable result been observed to follow its use. 

Ice. — In a case of severe convulsions in a new-born infant recorded by 
Dr. Ellwood Wilson {Phila. Med. Times, Nov. 1, 1873, p. 65), the intro- 
duction of a small conical piece of ice into the rectum immediately arrested 
the paroxysm each time. 

We shall here conclude our remarks upon the general treatment of 
eclampsia, and proceed to make some observations on the conduct to be 
pursued under particular circumstances. 

It is always highly important for the direction of the treatment, to dis- 



TREATMENT. , 549 

cover the cause of the attack. This is sometimes very easy, while in other 
iustances it is exceedingly difficult, and not unfrequently impossible. If 
the attack occur in the course of some acute disease, a^ pneumonia, catarrh, 
angina, enteritis, or dysentery, or during the progress of one of the erup- 
tive diseases, the diagnosis of the case is, as a general rule, very easy. If, 
on the contrary, it occurs at the commencement of one of these affections, 
the diagnosis will be much more difficult, unless indeed the symptoms of 
the concomitant disease have already declared themselves, or should do so 
very soon after the convulsion. The treatment in such cases should be that 
laid down in our general remarks, modified, however, by the requirements 
of the particular disease during the course of which the eclampsia occurs. 
When the attack occurs suddenly in a child previously in good health, 
-r who had been merely slightly ailing for a few hours, the detection of 
;he cause is still more difficult. The most probable causes under such cir- 
cumstances are, however, dentition, indigestion, intestinal disorder, or the 
approach of an acute general or local disease. It is easy to determine by 
inquiry of the attendants, and by examination of the mouth, whether the 
child is teething or not. As a general rule, the convulsions which depend 
solely on the process of dentition, are slight, and last but a short time. 
In all the instances that we have seen, in which such was the only cause 
to be detected, the attack was of this nature. The treatment in such in- 
-lances is to lance the gums, if they are swelled and inflamed over the 

dvancing teeth ; to use warm baths, and to administer purgative and then 

.ntispasmodic enemata. These simple means will seldom fail when eclamp- 
sia depends on the process of dentition alone. But when, on the contrary, 
there is present indigestion, intestinal accumulations, or enteritis, as often 
happens during dentition, the case becomes more serious, and requires in 
addition to the treatment above described, one directed to the particular 
coexisting morbid condition. 

The existence of indigestion as the cause of the attack, can be discovered 

rdy by ascertaining with great care the diet of the child during the pre- 
vious days. If it appear that something of an indigestible nature has been 
eaten within a short time, and if, at the same time, it be impossible to de- 
tect any more evident or probable cause for the attack, we should have a 
right to conclude that it depends upon indigestion. Under these circum- 
stances the proper treatment is the immediate use of the warm bath, and 
the earliest possible administration of an emetic of ipecacuanha. The 

peration of the emetic may often be hastened by tickling the fauces with 
a quill. 

The presence of intestinal accumulations as the cause of the paroxysms 
may be inferred, when it is found upon inquiry that the patient has been 
f"n-tipate<l for some days, or that the stools have been scanty and hard, or 
j-«aiiiy and ver\' offensive; when the abdomen is distended and hard, and 
the distension is a-scertained by palpation and percussion, not to be merely 
tympany ; and, lastly, when there is no more evident cause for the attack. 
In puch a case the particular treatment is the use of purgatives and en- 
emata, in addition to the other moans detailed. 

If the rhild presents the aymptom-; of dy-pepsia and malnutrition, asso- 



550 LARYNGISMUS STRIDULUS. 

ciated with anaemia, and the convulsions recur during a long period, the 
most scrupulous care must be taken to secure a nutritious digestible diet, 
combined with the use of tonics and iron. 

The dependency of the attack on the approach or commencement of 
some acute general or local disease, can be inferred only from a very care- 
ful examination of the antecedent and present phenomena of the case. 
One of these may be suspected as the cause when we can account for the 
occurrence of the convulsion on no more reasonable supposition ; when 
neither dentition, indigestion, nor intestinal irritation exist. It is scarcely 
likely that a convulsion could be occasioned by any of the acute thoracic 
or abdominal affections, unless the disease had already gone far enough to 
allow a careful examination of the different rational and physical symp- 
toms, to determine its existence. Perhaps the most difficult cases to diag- 
nosticate, are those which occur at the beginning of the eruptive fevers. 
Even here, however, a careful search for the prodromic symptoms of the 
disease, a watchful observance of the condition of the patient in and after 
the paroxysm, will generally lead to a correct opinion within a few hours, 
or after a day, and sometimes at the moment of the attack. Of the erup- 
tive diseases", scarlet fever is much the most apt to be accompanied by con- 
vulsions at the onset, and in that disease the remarkable rapidity and ac- 
tivity of the pulse, the state of the fauces, the heat of skin, and early 
appearance of the eruption, will generally enable us to understand the 
cause of the convulsion at a very early period. 

The treatment of sympathetic eclampsia depending on acute thoracic or 
abdominal disease, should be that which is proper for the particular malady 
which they complicate, with the addition of warm baths, revulsives, anti- 
spasmodics, and, after depletion, of opium, in the form of Dover's powder 
combined with nitre. The management of the convulsions which compli- 
cate the eruptive fevers, will be specially treated of in the articles on those 
maladies. 



ARTICLE VII. 



LARYNGISMUS STRIDULUS. 



Definition; Synonyms; Frequency. — Laryngismus stridulus belongs 
to the class of neuroses. It is characterized by crowing inspirations, or 
by momentary suspensions of the act of respiration ; these attacks occur 
suddenly, and at irregular intervals, are of short duration, cease suddenly, 
and are unaccompanied by cough, or other signs of irritation of the larynx. 
If the disease progress, it becomes associated with other convulsive symp- 
toms, as strabismus, distortion of the face, carpopedal spasms, or general 
convulsions. 

It is " the peculiar species of convulsion " of Dr. John Clarke ; the in- 
ward fits of Underwood ; the spasm of the glottis of Marsh, West, and 



PREDISPOSING CAUSES. 551 

Vogel ; the laryngismus stridulus of Good ; the croup-like convulsion of 
Dr. Marshall Hall ; child-crowing ; the spasme de la glotte of some of 
the Fr'encli writers ; one form of the internal convulsion of ISIM. Trous- 
seau and Pidoux, of MM. Rilliet and Barthez, and of J. L. Smith ; and 
the thymic a^^thma of some of the German authors. It is described by 
Eberle under the title of carpopedal spasms. 

The frequency of the disease seems to vary in different countries. In 
France it would ap}>ear to be somewhat rare. MM. Rilliet and Barthez 
(2erae 4dit.) speak of having seen nine cases. At the time of publication 
of their first edition, they had met with only one case, and then stated 
that they were acquainted with only one other, published by ^I. Constant 
in the Bui/etin de Thcrapeutique. M. Blache (article N^vrose du Larynx, 
Diet, de M(d., t. xvii, p. 590) adyerts very cursorily to one case. M. Val- 
leix ( Guide du Med. Prat., art. Asthme Thymique") doubts its existence as 
a distinct disease. In Germany, on the contrary, it would seem to be a 
rather frequent disease. In England it cannot be very infrequent, since 
Merriniau says it is by no means uncommon. Copland {Stridalous Laryn- 
r/ic Snfiocntio)} in Children, Diet, of Prac. Med.) speaks of numerous cases 
that he has seen, and states that he has had as many as three under treat- 
ment at the same time. Ley speaks of having met with considerably above 
twenty cases. Dr. Marshall Hall remarks that " within the short space of 
one month, I have seen five cases of croup-like convulsion." Dr. Charles 
West (4th edit., p. 162) mentions thirty-seven cases of which he has pre- 
served some record. The statements of more recent English writers indi- 
cate that it continues to be of quite frequent occurrence. 

We do not think it is a common disease in Philadelphia, though it is 
certainly not extremely rare, since we have either seen ourselves or heard 
of the occurrence of a comparatively large number of cases. 

Predisposing Causes. — ^lye. — It is generally acknowledged that the 
disease occurs most frequently during the period of the first dentition, 
though it has been known to occur as late as six or seven years of age. 
Of oO cases .selected indifferently from our practice and from authors in 
which the age is given, 13 were six months or less of age, 11 between six 
months and one year, 4 between one and two years of age, 1 of two, and 
1 of four years of age; so that of the 30, 24 were under one year. It is 
evident, therefore, so far as these cases go, that the majority occur within 
the first, and very few after the second year. 

Of the 37 cases mentioned by Dr. West, 31 occurred in children be- 
' n six months and two years of age. All the cases seen l)y MM. liil- 
nnd Barthez were in children under two years old. Those authors 
'tate that the seven subjects observed by M. H6rard were more than two 
years of age, and that two of them were between three and four years old. 
From the statements made by authors in general, it would seem to be 
most frequent between the ages of three weeks and eighteen months. It 
has been known, however, in one very rare instance, to occur as late as 
seven years of age. 

Ser. — It is most frequent in the male sex. Of 50 cases (4o from authors, 
and 5 by ourselves), 39 occurred in boys, and 11 in girls. MM. Itilliet 



552 LARYNGISMUS STRIDULUS. 

and Barthez state that of 16 cases observed by themselves and by M. He- 
rard, 12 occurred in boys, and 4 in girls ; of 183 cases collected by M. 
Lorent, in which the sex was noted, 125 occurred in boys, and 58 in girls. 

Constitution. — It seems established that it sometimes occurs in the most 
healthy and vigorous subjects, being then probably dependent upon reflex 
nervous irritation. It is, however, far most frequently met with in chil- 
dren who are delicate and feeble, and especially in those of scrofulous or 
rickety constitutions. The very frequent association of rachitis with laryn- 
gismus has been more and more prominently developed during the past 
few years. Some high authorities, since the publication of Elsasser's re- 
searches, in 1848, have even asserted that this connection is a constant 
one, and that laryngismus is essentially dependent upon craniotabes or 
rachitic disease of the skull. There are certain cases in our own expe- 
rience, and others which are reported by careful observers, which do not 
allow us at present to admit that this connection is an invariable one, but 
there can be no doubt that in the great majority of cases laryngismus oc- 
curs in rachitic children, and particularly in those who have craniotabes, 
or "soft spots" in the occiput. It not unfreqently attacks several chil- 
dren in a family. Ley quotes four instances from other writers, in which 
three children in each family had the disease, and in one all three died. 
He states that his own experience fully confirms this fact. 

MM. Killiet and Barthez (2eme edit., note, t. ii, p. 527) state that 
Davies and Henrich have met with four, and Torgord five children of the 
same family affected wdth the disease. They quote from Reid the curious 
fact that Powell saw one family of thirteen children, not one of which 
escaped the disease. 

Amongst the causes of the disease, in addition to those already men- 
tioned, must not be forgotten dentition and imioroper food. These two are, 
indeed, probably the most influential of all in the production of the com- 
plaint. The age at which it occurs most frequently, the last half of the 
first, and the first half of the second year, the very period during which 
the process of dentition is most active, would alone go far to show that 
this must constitute one of its most powerful predisposing, if not exciting, 
causes. The opinions of writers on this point are also conclusive as to the 
great influence of this vital process. Improper food, and especially early 
weaning, and the attempt to bring the child up by hand, is clearly a potent 
predisposing cause of the disease. This has been clearly shown in the 
cases that have come under our own observation, and especially in one in 
which contraction with rigidity followed the symptoms of laryngismus. 
The details of this case will be found appended to the article on contrac- 
ture. Dr. James Reid, in an excellent work on the disease (see Brit, and 
For. Med.-Chirurg. Rev., July, 1849, p. 163), gives the following conclu- 
sions as to its etiology: " 1. That for the occurrence of this complaint, the 
cerebro-spinal system is required to be in a peculiarly excitable state, 
which then acts as a predisposing cause. The period of teething is the 
most likely to produce this condition. 2. That during this irritable state 
of the nervous centres, the two most frequent (and in the majority of in- 
stances the combined) causes are the improper description of food which is 



NATURE — CAUSES. 553 

administered to the infant, and the impure and irritating atmosphere which 
it breathes." It must not be forgotten that while in some oases these causes 
act in producing kiryngismus by reflex irritation from the gums or mucous 
membraneof the alimentary canal upon a weak and over-sensitive nervous 
system : in other cases, the laryngismus is essentially connected with rickets, 
which has been induced by improper feeding. 

XATrRE AND ExciTiNG Cai'ses ; FoKMs. — ^Nluch difference of opinion 
has prevailed in regard to the nature and exciting causes of laryngismus 
stridulus since the disease has attracted the particular notice of the pro- 
fession. Kopp and other German authors ascribe it to compression of the 
respiratory organs by an enlarged thymus gland, while others of that na- 
tion, and some of the English and French writers, class it amongst the 
neuroses. Dr. Hugh Ley supposed it to depend on compression of the par 
vagura nerves by enlarged cervical and bronchial glands. Dr. Marshall 
Hall considers it to be a disease of the reflex system of nerves. Amongst 
the French writers, ^IM. Killiet and Barthez regard it as a neurosis; Val- 
leix and Trousseau treat of it as one form of convulsions in children ; 
Blache ( Diet, de Med., t. xvii, p. 584) speaks of it as a neurosis of the 
larynx, which may be either symptomatic or idiopathic. Many recent 
authors, as already stated, are disposed to regard it as dependent upon the 
irritation of the brain due to the existence of craniotabes. 

Before examining in detail the different opinions quoted above, which 
we propose doing, we will refer to the anatomical appearances of the 
malady. 

The mucous membrane of the air-passages, as a general rule, is found 
perfectly healthy, presenting neither redness, inflammatory swelling, 
oedema, nor accidental products of any kind. The lungs are usually of the 
natural color and density, and crepitant. M. Herard (Bib. du Mid. Praf., 
U V, pp. .319, 320) observed that in several autopsies made by himself, 
they always presented one marked change from their natural condition, 
however, which was a very high degree of emphysema, more general and 
strongly marked than in any other disease. This alteration is believed to 
depend, as it does in hooping-cough, upon the impediment to respiration 
which exists during the disea.se. MM. Killiet and Barthez state, however, 
that emphysema was not pr&sent in any of their autopsies. 

The heart and great ve?jsels of the thorax often, but not always, contained 
more bhmd than usual, as in asphyxia. 

M. H^rard states that he has made very minute researches in regard to 
the condition of the nervous system, examining the brain and spinal mar- 
row, the pneumogastric, recurrent, and diaf)hragmatic nerves, and tliosf; of 
the extremities even, to their terminations, without, however, findifig im- 
portant lesions in any cai»e. He exceptij only .serous effusion in small (juan- 
tity, and evidently consecutive, in the ventricles and particularly in the 
memltranes of the lirain, and slight venous congestion of the same kind. 
The tisf*ue*» of the brain and spinal marrow retained their ordinary' consist- 
eoce, and pre*»ente<l neither redness nor softening. 

The condition of the pneumogastric nervea has, however, licen variously 



654 LARYNGISMUS STRIDULUS. 

reported by different authors, some haviog found them softened, others 
indurated. 

In some cases tuberculosis of the lungs or bronchial glands has been ob- 
served. But as these, as well as all the other lesions mentioned, are not con- 
stant, they cannot be regarded as characteristic. In many instances more 
or less marked evidences of rickets are discovered upon the bones of the 
cranium, the ribs, or the long bones of the extremities. 

We will now examine as succinctly as possible the different opinions 
which have been advocated in regard to the causes of laryngismus stridu- 
lus. These may be classed, it seems to us, under four heads. 1. Enlarge- 
ment of the thymus gland. 2. Enlargement of the cervical and bronchial 
glands. 3. Organic disease of the cerebro-spinal axis. 4. That which re- 
gards it as a simple neurosis, without appreciable anatomical alterations. 

1. Enlargement of the Thymus Gland. — That the disease is in some cases 
coincident with, if not dependent upon, this condition, is proved by the 
observations of Kopp, Hirsch, Haugsted, Kyll, and others. Hasse {Pathol. 
Anat., Syden. Soc. Ed., p. 384) says there can be little doubt that it some- 
times depends upon this cause. 

It appears to us, however, that it has been clearly shown by M. Herard 
(loc. city pp. 320, 321), that the disease is entirely independent of any altera- 
tion of the thymus. That observer found that in six children between two 
and four years old, dying of the affection, the gland weighed between half 
a drachm and a drachm in five, and four drachms and two scruples in the 
sixth. These cases alone show that the size of the gland varies greatly in 
different subjects attacked with the disease. M. H4rard has examined the 
gland, with a view to the elucidation of this point, in sixty children dying 
with various diseases, between two and four years of age (the age of those 
who had died of the disease under consideration). In fifty he found that 
it presented the same arrangement, color, density, and weight, as in those 
who had perished with laryngismus stridulus. 

All of these subjects exhibited the same aspect ; they were pale, thin, 
and most of them exhausted by diarrhoea. In ten of the sixty the gland 
was much more voluminous, weighing from two to two and a half or five 
drachms, and in one instance an ounce and a quarter. The ten subjects 
upon which these observations were made, died of different diseases, croup, 
acute laryngitis, asthma, meningitis, and varioloid. All exhibited the ap- 
pearances of strong and vigorous health ; the one which presented the 
largest gland was very fat, and so robust, that, though only twenty-two 
months old, he looked to be three or four years. It appears to result 
therefore from these researches, that the gland is liable to great variations 
of size, and that its size bears a very exact proportion to the force of the 
child, being small in those who are slightly developed, or emaciated by 
chronic disease, and voluminous in those who are vigorously constituted, 
or who have died of acute diseases. 

That the disease does not depend, at least in all cases, on this cause, is 
shown also by Haugsted {Arch, de Med., t xxxiii, 1833, p. Ill), who re- 
ports the case of a girl, seven years old, in whom the gland weighed five 
ounces, and measured four inches long, and one and a half in thickness, 



NATURE — CAUSES. 555 

without its occasiouiug the least difficulty of breathing of any kind. That 
it occui-s in children in whom the gland is very small, is shown also by 
Campari and Pagenstecher (^quoted by Hasse, loc. cif.). 

2. Enlargement of the Cervical and Bronchial Glands. — This coudition 
as a cause of the disease, so strongly advocated by Dr. Ley, and adopted 
upon his authority by Kyll and Hasse, would seem from certain facts and 
arguments to be of doubtful agency. 

Thus, Mr. Wakely (quoted by Kerr) states that "he possesses more 
than one case of tubercular aftection in children, where the pneumogastric 
nerve has been completely flattened by the pressure of tubercles, without 
giving rise to any remarkable disturbance of the function of respiration." 
Dr. Hall doubts the correctness of this explanation of the phenomena of 
the disease, and says that if the contiguity of enlarged glands with the 
pneumogastric nerve have any effect, it is by their action upon it as an 
incident excitor, and not as a motor or muscular nerve. 

3. Organic Dij*ease of the Cerebrospinal Axis. — That it may depend on 
this" cause is proved by a case mentioned by Dr. Coley (On Infants and 
Children, BelTs edition, p. 226), who states that in a fatal instance wliich 
occurred in his own family, the only morbid appearance found on dissec- 
tion was a large exostosis growing on the inner surface of the occiput, 
which compressed the cerebellum and produced chronic inflammation of 
the dura mater. No disease was discoverable either in the cervical or 
thoracic glands. Dr. Kyll {Arch. Gin. de Mid., t. xiv, 1837, p. 94) quotes 
a case from Dr. Corrigan, of Dublin, which had lasted three months, in 
gpitc of calomel, emetics, and antispasmodics. Attention was called by 
chance to the spinal column, when it was discovered that pressure over 
the third and fourth cervical vertebrie was very painful, and produced 
loud cries from the child. Two applications of four leeches, at an interval 
of two days, to that point, removed all the symptoms, and the child re- 
covered perfectly. 

Dr. M. Hall i Diseases and Derangprnentx of the Xervons System, 1841, p. 
99; states that the crowing inspiration may arise from affections of the 
centre of the excito-motory system. He quotes a case related to him by 
Mr. Evans, of Hampstead, of spina bifida, in which "there was a croup- 
like convulsion whenever the little patient turned so as to press upon the 
tumor." He states, moreover, that he found induration of the medulla 
oblongata in one case of the disease. 

Dr. West has also noticed occasional attacks of larj^ngismus stridulus 
in chronic hydrocephalus, occurring even before much enlargement of the 
head had appeared. 

4. Thai it is a Neurosis. — We have seen that in very few cases of laryn- 
gi.amus there is actual organic disease of the brain or spinal cord. It is 
necessary, therefore, to regard it as most frequently a purely spasmodic 
nervous affection dependent upon irritation of certain part* of the nervous 
system which are directly or indirectly connected with the muscles of the 
glottis. Almost all recent authorities concur in the main with this opinion. 

That it is not always, however, a neurosis, is also shown by the cases 
quoted under the first head from Drs. Hall and Coley, and by those in 



556 LARYNGISMUS STRIDULUS. 

which the disease is accompanied from the first by symptoms of inflamma- 
tion or congestion of the brain. 

It lias now been shown that the causes of the disease are exceedingly 
variable and uncertain, and that any opinion which asserts its dependence 
on one invariable and constant cause is untenable. AVe must, therefore, 
seek some explanation which shall reconcile, as far as possible, the facts 
related above, and harmonize the various opinions expressed by the authors 
quoted. 

It seems to us that the explanation given by Dr. Hall {loc. cit.), is the 
only one which accounts satisfactorily for the phenomena of the disease, 
and reconciles the contradictory accounts of its nature and causes brought 
forward. Dr. Hall regards it as an affection of the excito-motory or true 
spinal system of nerves, producing in mild cases partial closure of the 
glottis, and difficult inspirations, while in more severe cases the spasmodic 
disposition extends to other parts of the body, — to the eyeballs, and to 
the flexors of the fingers and toes. We have already alluded to his theory 
that in very violent attacks of laryngismus, where the glottis is entirely 
shut, the suspension of respiration produces congestion of the nervous 
centres and general convulsions. As already stated, however, this theory 
has not been accepted, and we regard the occasional occurrence of general 
convulsions in connection with laryngismus stridulus, as one proof that 
this latter affection is merely a partial and imperfectly developed convul- 
sion. 

The causes may be either centric, seated in the nervous centres, or cen- 
tripetal, in the excitor or incident nerves. In the great majority of cases, 
the causes are centripetal, consisting of various morbid conditions situated 
at the peripheral extremities of the nerves, which become causes in con- 
sequence of the irritation they establish in the nerve-extremities : this irri- 
tation is transmitted to the nervous centres, and thence reflected through 
the various efferent or motor nerves to the different portions of the mus- 
cular apparatus affected in the disease, the larynx, face, extremities, and 
lastly, in severe cases, the whole body. The principal causes of this class 
are dental irritation occurring during dentition ; gastric irritation, arising 
from excessive or improper food ; intestinal irritation from constipation, 
intestinal disorder or catharsis ; and perhaps the pressure of an enlarged 
thymus or of enlarged cervical or bronchial glands. 

The centric class of causes includes such as are seated in the nervous 
centres. These are much less common than the former class, and give rise 
to a vastly more dangerous and intractable form of the disease. Foremost 
among them, according to recent observations, must be placed the devel- 
opment of " soft spots " in the occipital bone in connection with rickets, 
which allows pressure upon the back of the head to induce irritation of 
the brain. Indeed, the more this subject is investigated the closer and 
more frequent does the connection appear to be between laryngismus and 
rickets. There are also different morbid conditions of the brain and spinal 
marrow, as inflammation, congestion, and effusion, which appear to have 
occasionally proved the cause of laryngismus. That such causes some- 
times produce the disease is shown by the cases of exostosis already quoted 



SYMPTOMS. 00 ( 

from Coley, that of spinal irritation from Kyll, that of Dr. Hall, in which 
he found induration of the medulla oblouirata, and the one of spina bifida 
reporteil to Dr. Hall by Mr. Evans. In the latter case the tumor was 
seated on the loins. Mr. E. proposed to treat it by compression, but on 
making the attempt found that it was followed immediately "by the affec- 
tion described by Dr. J. Clarke" {HoH, loc. cit., p. 144). Other centric 
causes, which have been ascribed in some rare instances, are passion, vex- 
ation, fright, contradiction, etc., etc. 

This theory of the nature of the disease likewise accounts for the vary- 
ing character of the convulsive symptoms. The laryngeal spasm, from 
which the disease derives its name, does not constitute the whole malady ; 
it is only one of the symptoms, though the principal one, and that by which 
it is particularly characterized. The other convulsive phenomena, which 
generally occur only in severe attacks, or after the disease has continued 
for some time, are distortion of the face; strabismus, carpopedal spasms, 
and general convulsions. The hydrocephalic symptoms which occur to- 
wards the termination of such cases, and the serous eflusion within the cra- 
nium found after death, are, it ought to be recollected, often the conse- 
quences of the congestion of the brain and asphyxia, which take i)lace 
during the more or less complete closure of the larynx. 

Symptoms ; Course ; Duration. — Laryngismus stridulus begins sud- 
denly with a paroxysm of difficult respiration. The larynx is contracted 
spasmodically, and the entrance of air into the lungs is either prevented 
or impeded. In most cases the closure of the larynx is only partial, and 
the respiratory movement continues, but is accompanied by prolonged and 
difficult inspirations, which give rise to the crowing or stridulous sound, 
whence the disease derives its name. The crowing sound is generally 
heard several times in each paroxysm, owing to the repeated but only 
partially successful attempts at inspiration ; while in very violent cases it 
occurs only at the beginning and end of the accession, the respiration 
being entirely suspended in the middle period. At the same time the 
child presents an appearance of great distress. The body is thrown forci- 
bly backwards, the eyes are fixed and staring, the nostrils dilated, and 
the whole countenance indicative of great anxiety. If the paroxysm con- 
tinues many seconds, the face becomes bluish, the extremities cold, and 
the fingers and toes contracted. After a few seconds, or a minute, or 
even longer, the spasm of the larynx cea.se« ; a loud, full inspiration 
takes place ; a fit of crj'ing generally follows, and the child eithtjr very 
soon regains its usual spirit.*, or, if the paroxysm have been very severe, 
seems weak, languid, and drowsy, and returns more slowly to its ordinary 
condition. Between the paroxysms the child may seem perfectly well so 
fer as concerns the character of the respiration, but it almost always 
exhibits the symptoms of some derangement of the general health, or, in 
other words, of the morbid condition which is the ultimate cause of the 
laryngeal spasm. 

The paroxysms are most apt to occur during sleep, or as the child is 
waking. They occur spontaneously, and are brought on by fretting or 
crving, coughing, fright, contrarieties, deglutition, by the sudden applica- 



558 LARYNGISMUS STRIDULUS. 

tion of cold, and other sudden impressions. At the commencement of 
the disease they recur at rare intervals, and often attract little notice ; 
but, as the case progresses, they become more frequent, and may amount 
to twenty or thirty in the day, according to Kerr. They sometimes cease 
entirely for some weeks, or even months, and then recommence. In a 
case attended by one of ourselves (reported in the Am. Jour. Med. Sci., 
April, 1847, p. 287), the attacks lasted eighteen days, occurring some- 
times two or three times in an hour, and sometimes much less frequently. 
The child then recovered entirely for a period of seven months, when the 
disease returned, and after continuing for five days, caused the death of the 
child in one of the paroxysms. 

If the disease continues to progress, it almost always becomes associated 
with other spasmodic symptoms. The thumbs are drawn tightly into the 
palms of the hands, and the fingers clasped over them, which gives to the 
back of the hands a swelled and tumid look. At the same time the toes 
are strongly flexed under the feet, and the insteps look swelled like the 
backs of the hands. Sometimes the hands are bent on the forearms, and 
the forearms on the arms. There is often distortion of the face. In severe 
cases, or when the disease has continued for a considerable period, epilep- 
tiform convulsions make their appearance, and generally prove fatal. 

The disease is apyretic in a large majority of cases. When fever arises 
it almost always depends on the condition which has occasioned the dis- 
ordered action of the excito-motory system, or on some accidental compli- 
cation. The pulse during the paroxysm is small, corded, rapid, and some- 
times imperceptible. In the intervals it is natural or nearly so. 

Death may occur very early in the disease, or after some weeks, months, 
or according to Kyll, years. Vogel states (op. cit., p. 272) that " some- 
times even the very first attack terminates in death, and a seemingly per- 
fectly healthy child may be carried ofi* in a few seconds." In a case quoted 
by MM. Rilliet and Barthez, death took place at the end of three weeks, 
and in another, in twenty months. 

The duration is very uncertain. It generally, however, lasts several 
months. In one of our own cases it lasted eighteen days, then ceased for 
seven months, returned, and proved fatal in five days. In another case, 
the attacks of spasms returned from time to time, during a period of three 
weeks. In another case, the notes of which were obligingly furnished us 
by our friend Dr. Benedict, and which we shall append to this article, it 
lasted, in connection with contracture, four months and a half, and was 
followed by perfect recovery. 

Other Forms of Internal Convulsions. — We have, for the sake of clear- 
ness, limited ourselves so far in the present article, to cases where the spasm 
is confined to the muscles of the larynx, when the attack might be called 
one of laryngeal convulsion. 

In other cases, however, the spasm may affect, either solely, or in con- 
junction with the larynx, the diaphragm, and the respiratory muscles of 
the abdomen and chest, constituting what is termed by some authors " in- 
ternal convulsions.'^ The most common form of internal convulsion as 



SYMPTOMS. 559 

described by Trousseau, " is characterized by rolling upwards of the eye- 
ball?:, by au almost complete loss of consciousness, by extreme difficulty 
or impossibility of deglutition, by irregular respiration, at times barely 
perceptible, or free, deep, and blowing, indicating that the diaphragm and 
the respiratory muscles of the abdomen and chest are especially affected." 

These internal convulsions may be associated with partial or even gen- 
eral convulsions of the face and extremities; more frequently, however, 
they are accompanied by more or less general tonic muscular contraction. 

In most cases, as indicated in the passage quoted from Trousseau, the 
muscles of the pharynx are involved, and there is marked dysphagia or 
utter inability to swallow. 

In some instances, also, the frequency, irregularity, and sraallness of the 
pulse, and the irregular and tumultuous character of the action of the 
heart, indicate, as pointed out by Rilliet and Barthez {op. cit., t. i, p. 510), 
that the organs of circulation probably share in the convulsion. 

The degree in which the larynx participates in the attack varies much 
in different cases ; at times there is no obstacle whatever to the entrance 
or exit of air through its cavity, at others, the spasm of its nmscles is so 
extreme that the passage of air is entirely obstructed ; whilst in still other 
cases, of which the one communicated to us by the late Prof Pepper, and 
quoted at the end of this article, is an example, respiration is difficult and 
accompanied by a stridulous noise. 

The above description applies to those cases of internal convulsions where 
the convulsion is complete, and presents both the primary tonic contrac- 
tion and the subsequent clonic spasms of the respiratory muscles. 

But in other cases, the attack consists merely of a sudden tonic spasm 
of the diaphragm and respiratory muscles of the abdomen and chest, fol- 
lowed by a sudden and complete relaxation. The entire suspension of the 
respiration during the spasm would of course rapidly induce fiital asphyxia, 
but fortunately the attacks, as we have met with them, have usually been 
so brief as not to cause any dangerous symptoms. 

The.se attacks are popularly known in this country, and were described 
in the earlier editions of this work, under the title of " Holding-breath 
SpeU^r 

We have met with a considerable number of well-marked cases of the 
affection, and believe it to be of quite common occurrence. It seldom 
happens that the physician is consulted in regard to it, as those who have 
charge of children in whom it occurs, almost always ascribe it to temper, 
and think it of but little moment. It api)ears to be the result of a sudden 
spasm of all the respiratory mus^des, so that the chjld ceases for the time 
to breathe, from which circumstance, no doubt, it has received its name of 
"holding-breath spell." There is no stridulous sound, nor hoarseness of 
the cry, nor indeefl sound of any kind. The face is contracted and bluish, 
the base of the thorax retracted and immovable, and the limbs violently 
agitated at first, and then stiff; after a few seconds, or perhaps a minute 
in severe ca«es, the spasm yields, the child instantly makes a full inspira- 
tion, unattended with stridulous sound, and generally bursts into a loud fit 
of crying, which lasts for a few moments, after which the child seems {^r- 



560 LARYNGISMUS STRIDULUS. 

fectly well, or else the attack is followed by excessive paleness, with lan- 
guor or prostration, lasting half an hour or even longer. The attacks 
recur with variable frequency ; there may be several in a day, or but one, 
or they may occur only at intervals of several days. The most frequent 
cause of the paroxysms is contradiction. They are determined also by 
fright, pain, and crying. They never occur spontaneously, and never dur- 
ing sleep, so far as we know. It is to be distinguished from laryngismus 
stridulus by the absence of the crowing sound, by its not occurring spon- 
taneously or during sleep, and by the absence of carpopedal or other spas- 
modic symptoms. It is, we believe, a spasmodic affection of respiration, 
analogous to though not exactly similar to laryngismus stridulus. We 
have never met with it except during the period of the first dentition, and 
always in children of nervous temperament. The cases that we have met 
wdth all recovered, and in one only did the life of the child seem to be at 
all endangered. In this instance the paroxysms had recurred very fre- 
quently for eleven months, and on two occasions were terminated by slight 
spasmodic movements of the limbs, lasting only for a few instants, and 
unaccompanied by insensibility or other dangerous symptoms. After these 
attacks the child was removed to the country, where he recovered perfectly. 

Diagnosis. — The only disease with which laryngismus stridulus is likely 
to be confounded is spasmodic laryngitis, or false croup. From this it may 
readily be distinguished by the absence of catarrhal symptoms, or fever; 
by the fact that the paroxysms occur indifferently in the day or night, and 
that they are much more frequent ; by the duration of the paroxysms, 
which last only a few seconds, or more rarely a minute ; by the absence 
of cough or hoarseness of the voice, even during the height of the par- 
oxysm ; by the occurrence of tonic muscular spasms, and convulsions ; 
and, finally, by the chronic course of the malady : the converse of all of 
which symptoms exist in spasmodic croup. 

Prognosis. — The prognosis of laryngismus stridulus is always serious, 
since even the mildest cases may terminate fatally in any one of the par- 
oxysms. It is, however, far from being so dangerous a disease as has been 
supposed by some writers, and amongst others M. Valleix, who states that 
it is almost always fatal {Guide du Med. Prat, t. i, p. 564). Of 56 cases 
collected from Pagenstecher, Hachman, Ley, Kopp, Hall, Constant, Killiet 
and Barthez, Kyll, and 5 from our own observation, making 61 in all, 4 
died of intercurrent or consecutive diseases, while of the remaining 57, 32 
were cured, and 25, or about 43 per cent., died of the malady itself 

MAr. Rilliet and Barthez quote from M. Lorent, the translator of Dr. 
Reid's work, the statement, that of 289 cases collected from various 
writers, 115, or rather more than 39 per cent., proved fatal. 

The prognosis given by the physician ought to depend in great measure 
upon the cause of the malady. When it depends on difiicult dentition, 
improper diet, or gastro-intestinal disease, whether or not connected, as 
they very frequently are under these circumstances, with rickets, the case 
will in all probability terminate favorably if the proper treatment can be, 
and is, brought to bear against those morbid conditions ; while if it occur 



TREATMENT. 561 

under the influence of a centric cause, or of enlargement of the cervical or 
bronchial glands, the prognosis becomes much more unpromising. 

Treatment. — If the views taken of the nature of the disease in the 
above remarks be correct, it must be evident that for the treatment to 
otier any considerable chance of success, it must be directed not merely to 
the removal of the spasm of the larynx, which is only a symptom and 
not the whole disease, but to the remedying of the deeper-seated cause of 
the disordered functional action of the excito-motory system of nerves. In 
this connection it is especially important to search for the symptoms of 
rickets, which we have seen to be so often the primary underlying cause 
of the attacks. 

When the disease seems to immediately depend upon difficult dentition, 
the gums ought to be carefully watched, and freely scarified, so soon as 
there is the least heat or swelling over the advancing teeth. Dr. Marshall 
Hall deems the use of the gum-lancet one of the most important means 
of treatment we are possessed of, and recommends that the gums should 
be fully divided, "not once, or occasionally, but ttvice or even thrice daily." 
In another place, he says : " We should lance the gums freely and deeply, 
over a great part of their extent, daily, or even twice a day, and apply a 
sponge with warm water, so as to encourage the flow of blood." He even 
recommends that, in very urgent cases, the lateral as well as the more 
prominent jwrtions of the gum, should be scarified. Lancing of the gums 
is undoubtedly a most important point in the treatment of this and other 
diseases of childhood, connected with dentition. We have long been con- 
vinced, however, from personal observation, that ^ resort to this operation, 
merely because the child is passing through the period of dentition, is at 
least useless. We have never found it to do any good, unless the teeth are 
near enough to the surface to produce manifest swelling, attended with 
heat and soreness of the gums. So long as the gum is hard, insensible, 
not turgid, and of its natural color, and the mouth not hot, cutting has 
done no good. 

When the disease depends on gastric irritation, the result of an unhealthy 
milk or of artificial diet, or when there are evidences that these morbid 
influences have induced rickets, our attention must be directed principally 
to the removal of these conditions. A wet-nurse ought to be procured at 
once if one can be obtained, and if the child will nurse. If this cannot 
be dpne, the diet must be carefully regulated by the physician. Ass's milk 
or goat's milk ought to be used if they can be procured ; if not, we would 
r.r (.mmend the gelatin diet, prepared as recommended at page 332. The 
pr-. portion of the ingredients must be regulated by the condition of the 
r*tomach. If the digestive power be very weak, the proportion of milk 
must be only a fourth or even a sixth for a few days, while the amount of 
cream must bear its usual ratio to the milk. 

When the child is thin and pale, and the stomach evidently weak and 
dyspeptic, it is well to resort to small quantities of stimulants, and to 
tonics in proper doses. The best stimulant is fine old brandy, of which 
from ten to twenty drops may be given three or four times a day, or every 
two or three hours. Or we may administer the aromatic spirit of hart»- 

86 



562 LARYNGISMUS STRIDULUS. 

horn in connection with, or without the brandy ; of this about ten or fifteen 
drops should be given four or five times a day, or alternately with the brandy. 
Of tonics, the most suitable, it seems to us, are quinine, in the dose of a 
quarter to half of a grain three or four times a day, or the citrate of iron 
and quinine, in the dose of half a grain, given in the same way. Another 
very excellent stimulant and tonic is the Huxham's tincture of bark, of 
which about five to fifteen drops may be prescribed in the place of brandy. 
This kind of treatment will scarcely fail to stimulate the digestive power 
of the stomach to greater activity after a few days, and of course to im- 
prove the nutritive functions and the strength of the patient. In addition 
to this we would recommend the persistent use of the remedies which, as 
cod-liver oil and the compound syrup of the phosphates, are most bene- 
ficial in the treatment of rickets. The reader is referred to the article on 
the latter subject for more detailed discussion of this point. 

When the disease is associated with marked intestinal irritation, we must 
inquire carefully into its nature and causes. It may be connected with 
constipation, diarrhoea, or with an unhealthy state of the contents of the 
bowels. It is often dependent on the presence of crude or imperfectly di- 
gested food in the alimentary canal, and when this is the case, the only 
proper method of treatment is to attend to the state of the digestive func- 
tion, and to discover and employ a proper diet. The bowels are quite 
frequently very torpid, and the stools, when obtained by medicine, are 
often found to be very oflfensive, light-colored, and pasty, conditions gener- 
ally resulting from imperfect action of the liver. Under these circum- 
stances small doses of mercurials, or taraxacum, should be resorted to in 
combination with or followed by mild aperients, as castor oil or rhubarb. 
One of the very best cathartic remedies, when this combination of symp- 
toms is present, is Chaussier's mixture of castor oil and aromatic syrup of 
rhubarb, consisting of three parts of the former rubbed up with five parts 
of the latter. The dose is a teaspoonful every two or three hours, until 
the bowels are well evacuated. It is gentle in its action, and yet very 
efllcieut, gives no pain, and is easily taken. If a mercurial be desired, 
about two or three grains of blue mass, one or two grains of calomel, 
or four grains of the mercury with chalk, may be incorporated into an 
ounce of the mixture. When diarrhoea is present, it must be treated 
according to its causes, as recommended in the articles on simple diar- 
rhoea and entero-colitis. When on the contrary, constipation is a marked 
symptom, this is to be treated by regulation of the diet, by the daily 
use of warm-water enemata (particularly recommended by Dr. M. Hall), 
or, if these do not answer, by the exhibition of small doses of the mildest 
aperients. 

Dr. Hall states that by strict attention to the dentition process, and to 
gastric and intestinal irritation in the dawn of the disease, he has succeeded 
in curing all the cases he has seen but one, and in that he found induration 
of the medulla oblongata. 

By those who suppose the disease to depend on enlargement of the thy- 
mic, cervical, or bronchial glands, it has been proposed to endeavor to 
procure a reduction of the hypertrophy of those glands by frequent appli- 



TREATMENT. 563 

cations of leeches, by the use of exutories upon the thorax, by the employ- 
ment of strong purgative medicines, and by the administration of mercury, 
digitalis, and iodine. In a case apparently connected with enlargement of 
the bronchial or cervical glands, we should prefer to direct our treatment 
to the invigoration of the general health by attention to diet, by the use of 
tonics, and by proper exposure to fresh air, whilst we should employ inter- 
nally, cod-liver oil, iron, iodide of potassium, the preparations of iodine, 
and antispasmodics. 

"When the disease depends on a centric cause, this must be treated, if it 
can be detected, according to its nature. 

Ajiti^pasmodic^. — Whatever be the causes of laryngismus stridulus, it 
is undoubtedly proper, whilst our chief efforts are directed towards their 
removal or mitigation, to make use of antispasmodics in order to moderate 
the spasmodic symptoms which are but the expression of those causes. The 
remedies of this class most highly recommended are bromides of potassium 
and ammonium, belladonna, valerian, musk, assafoetida, oxide of zinc, and 
small doses of ipecacuanha. One of the bromide salts mentioned should 
be given in full doses, and may be combined with any of the other anti- 
spasmodics. As stated in our remarks on the use of remedies of this class 
in hooping-cough, there is reason to believe that the bromide of ammonium 
possesses greater power than the other bromide salts in relieving the spas- 
modic affections of the larynx. The oxide of zinc which, as stated in the 
article on eclampsia, is so highly recommended by Brachet and others, 
may be given alone or combined with extract of hyoscyamus. M. Brachet 
always combines the oxide of zinc with extract of hyoscyamus, and gives 
;it least two grains of the former with four of the latter, in divided doses, 
in the twenty-four hours. He states that he has never given more than 
ten grains of each in the period mentioned. Of the fluid extract of vale- 
rian, about a tea.?poonful, or even more, might be given in the twenty-four 
hours, to a child one or two years old. It should be mixed with water, of 
course. 

It must never be forgotten, however, that remedies of this class are 
to be employed only as palliatives and adjuvants, and not as curative 
agents. 

Iron. — Of all the remedies to be employed, after attending in the strict- 
est manner to the removal of the exciting causes of the disease, there is 
none of such almost universal applicability as iron or its preparations. 
The patient is almost invariably, owing to the faulty state of the digestive 
and nutritive functions, more or less anirmical, a condition imperatively 
demanding iron ; and as this remedy rarely conflicts with the other means 
indicated, it should be given probably in all, or nearly all the cases. The 
nufallic iron in p<jwder or in lozenges, in doses of half a grain or a grain 
tliree times a day, or the irnlide of iron in doses of from two to four drops 
three times a day, in a mixture of syrup and cinnamon-water, are the best 
preparations, and they should be continued, as a general rule, throughout 
the treatment of the case. 

We have already referred to the great value of the prolonged use of 
remedies which improve the general nutrition, and particularly coun- 



564 LARYNGISMUS STRIDULUS. 

teract the rachitic diathesis so often preseot in cases of laryngismus. 
Among these may be mentioned cod-liver oil, arsenic, and the alkaline 
phosphates. 

Treatment during the Paroxysm. — When the child is attacked with a 
paroxysm of difficult breathing, it should be lifted at once into a sitting 
posture, if it be reclining, and fanned, or carried to an open window, if 
the weather be not too cold. At the same time cold water should be 
sprinkled upon the face, and if the attack be violent, we may resort to 
what is recommended by Dr. Hugh Ley and Dr. Hall, tickling of the 
fauces to produce nausea or vomiting, or irritation of the nostrils with a 
feather, so as to occasion gasping respiration. In a case which occurred 
to the late Dr. C. D. Meigs, accompanied with severe general convulsions, 
he found that the suspension of the respiration could very generally be 
broken in upon, and the paroxysm sometimes averted, by the application 
of a piece of ice, wrapped in a cloth, to the epigastrium and lower part of 
the sternum. 

Dr. Edmunds (Med. Times and Gaz., March 12, 1864) also found that 
the application of one of Chapman's ice-bags to the spine, did more than 
anything else to keep off the paroxysms in an obstinate case of laryngis- 
mus. 

To prevent congestion of the brain and effusion, which sometimes takes 
place as the effects of the attacks, Dr. Hall recommended a few leeches or 
cups to the head, the application of an alcoholic lotion over the whole 
head, or the use of the ice-cap. At the same time the bowels ought to be 
speedily moved by large enemata either of simple water or of water con- 
taining salt. 

In cases, especially of the more general form of internal convulsions, 
where the attacks are so frequently repeated and severe as to threaten life, 
we would recommend the induction of partial anaesthesia by either ether 
or chloroform, as advised in the article on eclampsia. 

Removal to the Country. — When the disease persists in spite of the means 
above recommended, and especially when it depends on dentition or diges- 
tive irritation, change of air will often produce a wonderful effect, and 
should always be tried. 

The following cases are reported in full, as illustrating the peculiarities 
and treatment of this curious affection : 

Case. — "The subject of this case was a boj; born in July. He was a large, 
hearty child, and remained well until January of the following year, when his 
mother's milk failed, and he was placed upon artificial diet. From this time to 
May following, his diet was cream and water, barley-water, oatmeal, arrowroot, 
pounded crackers boiled with water, and gum-water, all of which were tried in 
turn, being prepared and administered with the greatest caution as to time and 
quantity. A Avet-nurse was tried, but the child refused the breast entirely. 

" On the 27th January, he was attacked with diarrhoea, which lasted one week. 
This was followed by constipation, the stools being white, firm, tenacious, and offen- 
sive. The constipation continued up to July, when it was replaced by diarrhoea. 

•' February 4th. On this day, the child being seven months old, was first ob- 
served a spasm of the larynx, producing a shrill, croupal whistle, or ooh, och, during 
two or three successive respirations, and followed by a cessation of breathing for 



CASE. ' 565 

some seconds, long enough to dash water in his face, carry him to the window, pat 
him on the back, etc. These spells occurred durincr the sleeping and waking state, 
and especially during crying or laughing, and continued almost daily and often 
many times a day and night until June, when he was taken into the country. 

"Simultaneously with the laryngeal spasm, appeared contractions of the upper 
extremities, the thumb? being drawn tightly into the palms of the hands, the fingers 
flexed over the thumbs, and the hands bent on the forearms. The backs of the 
hands were swollen, and the skin looked tight and polished. 

" For a few days in the middle of February, there was a subsidence of all the 
symptoms, with decided improvement in every respect. 

"On the 25lh of the same month occurred a return of all the symptoms, with ex- 
tension of the spasm to the feet, the toes being bent under the feet, the insteps much 
swelled and having a polished appearance. At the same time there were occasional 
spasmodic movements of the muscles of the face, arnis, and body, resembling those 
of chorea. This condition continued with occasional relaxations up to the lltl) of 
June. 

"The stomach was exceedingly delicate, rejecting the most carefully selected 
nourishment, and at times refusing all food. The child became pale, thin, and 
timid ; was disturbed by the slightest noise, and shunned the light as painful. 

" He was removed to the country on the 11th of June. There his health was 
gradually restored. The appetite improved, the spasm of the larynx and contrac- 
tions of the extremities gradually relaxed, and the thumbs were at last liberated, 
the skin under them having t^ken on the appearance of mucous membrane. There 
was no return of the disease after the middle of June, although the child had a 
severe attack of diarrhoea in July, after which he got perfectly well, and has re- 
mained so up to the present time (twelve months subsequently). The first tooth 
made its appearance in September, and be now has fourteen, and has cut them all 
without the lea?t accident. During the last eight months he has been remarkably 
fat and hearty. 

•* I am not aware that any medicine had any effect in removing the disease. 
Calomel, in large and small doses, antispasmodics of all kinds, frictions over the 
spine, blisters to the back of the head, alteratives, laxatives, etc., were persevered 
in without benefit. On removing him to the country, and feeding him on milk 
warm from the cow, at first diluted, and afterwards pure, an improvement was 
sf»eedily observed." 

The above case, which was communicated to us by Dr. Benedict, was 
probably a.s.«ociated with rachitis: unfortunately no record is made of the 
condition of the occiput. The result illustrates most strikingly the good 
effects of removal from the city to the country, and the adoption of a more 
healthy diet. 

Case. — The following case is one that occurred to one of us. "We extract the 
tccount of it from a paper on croup by Dr. J. F. Meigs {Am. Journ. Med. Sci., 
April, 1847). 

The patient was a girl, five months of age I saw the child on the 28ih of 
March, 1844. The first attack occurred the day before I was called, but as the 
mother ?upf>o8fd it to be a matter of little conscqupnee, she did not Rend for me 
until the next day. The child was well grown, and except a rather too groat pale- 
ness, looked strong and healthy. It was playful and good-humored, nursed freely, 
had no fever, and between the par<»xy»nis presented the appearances of perfect 
health. The crowing fits occurred frequently in the course of the day and night, 
•ometimes two or three times in an hour, or not so often. They ofien waked the 
little thing suddenly from tranquil sleep. They con^if»ted of a succession of long 
and difiScult inspirations, accompanied by a {*«culiar whistling or crowing sound, 



666 ' LAKYNGISMUS STRIDULUS. 

such as might be supposed to depend on the passage of air through a narrow aper- 
ture. During the attack the face assumed an expression of great anxiety, the re- 
spiratory muscles contracted with violence, and there seemed to be for the time im- 
minent danger of suffocation. After several seconds or a minute the shrillness of 
the sound diminished, the struggling subsided, and soon the respiration became 
perfectly natural, and the child seemed well. The paroxysms were usually fol- 
lowed by fits of crying, which, however, were easily pacified. 

The paroxysms gradually dim nished in frequency and violence, and ceased en- 
tirely after the 13th of April. The treatment consisted simply in careful atten- 
tion to the general health, and in the frequent use of warm baths and mild nau- 
seants. 

The child remained perfectly well, with the exception of a slight attack of chol- 
era infantum, until the following November, seven months after, when the disorder 
recurred. Several paroxysms occurred between the 12th and 17th of the month; 
but as they were slight and unattended by other symptoms of illness, the mother 
was not alarmed, and paid but little attention to them. On the 17th of the same 
month, the child was sitting on the floor amusing itself with some playthings. 
There were no persons in the room except young children. They saw the little 
thing stoop forward suddenly, as though in play, and did not therefore regard it 
immediately. As it remained in that position, however, they went to it, took it up, 
and found it dead. It had perished suddenly, no doubt in one of the paroxysms 
of laryngismus. 

An autopsy was made, in which the larynx and thoracic organs were examined, 
but nothing was found to explain the cause of the disease or the sudden death. 

In the following interesting case, communicated to us by the late Prof. 
William Pepper, the attack consisted of persistent laryngismus stridulus, 
accompanied by frequently recurring internal convulsions affecting the 
diaphragm and other respiratory muscles, and by tonic contraction of the 
muscles of the arm?. 

Case. — A boy, aged four months, remarkably healthy and well developed, after 
suffering a few days with slight catarrhal symptoms, was suddenly seized with a 
peculiar stridulous crowing respiration. 

I saw the child about half an hour from the commencement of the attack, and 
found it with a pulse of 140, pale face, and livid lips. The pupils were contracted, 
and the hands firmly clenched ; the crowing sound was very loud, and attended 
every act of inspiration. At times the respiration and circulation would be en- 
tirely suspended for many seconds, followed by great lividity of the surface and 
coldness of the extremities. 

Eight or ten leeches were applied behind the ears, the feet placed in warm water, 
and a dose of castor oil administered, to be followed by saline enemata. 

Four hours from the commencement of the attack, all the symptoms were greatly 
aggravated ; the wrists and fingers were firmly flexed, these spasms coinciding with 
the arrest of the circulation and respiration ; there was now perfect insensibility. 
The child was placed in a warm bath, cold water was applied to the head, and a 
sinapism along the spine, without, however, affording any relief to the crowing 
inspiration, or other spasmodic symptoms. 

At the suggestion of Dr. C. D. Meigs, the child was now placed on its right side, 
with the shoulders elevated; this position to be maintained at least six hours. At 
the end of that time the child was in no respect improved, and accordingly, at 
the suggestion of Dr. M., six leeches were applied over the cardiac region ; f^] of 
lac. assafoetid. was thrown into the rectum, and a blister applied to the back of the 
neck. 

The child expired at midnight, about ten hours from the commencement of the 



II 



CONTRACTION WITH RIGIDITY. 567 

attack, the crowing respiration, with more or less asphyxia, having: per-istod 
throughout. 

Auiopsv, ihirfy-six hours after Deaih. — Mucous membrane of the larynx injected, 
but in other respects natural. Thymus gland three and a half inches long, two 
and a half wide, and at its upper part three quarters of an inch thick ; its weight 
was 620 grains, or 10 drachms and 1 scruple. Lower lobes of both lungs greatly 
congested. Heart natural. The brain, unfortunately, could not be examined. 

It will be observed that, in the above case, the laryngismus and other 
spasmodic symptoms appeared after slight catarrhal symptoms had ex- 
isted for a few days ; and it may be possible that the irritation of the 
mucous membrane acted as the exciting cause of the convulsive attack. 
A recent author' has, however, alluded to the case in such a connection 
and manner, as to at least suggest that he may have mistaken it for one 
of spasmodic laryngitis. A careful consideration of the symptoms and 
course of the case will, however, sufficiently show its essential difference 
from this latter affection. 



ARTICLE VIII. 

COXTKACTION WITH RIGIDITY. 

This is the disease called by the French contracture. We shall treat 
of it a.s idiopatic contraction with rigidity. It has been little studied 
until of recent years, since then a number of cases have been placed on 
record, especially by French writers. We have ourselves met with but 
one well-marked example of it in an independent form. This case, of 
which we shall give a sketch at the end of this article, and the one of 
laryngismus stridulus communicated to us by Dr. Benedict, and appended 
to the article on that disease, furnish very good examples of contraction 
coexisting with the former affection. We have seen also two other ca.se8 
in which the contraction was decided, but in which it lasted but a short 
time. 

The di.sease is evidently one of the forms of excito-motor disturbance, 
which prei?ent themselves under such a variety of shapes during infancy 
and childhood. Though it generally exists as an idiopathic and distinct 
malady, it is in other cases as.«ociated with, or follows laryngismus strid- 
ulus or spasm of the glottis, and in others again is combined with attacks 
of general convulsions. 

Definition. — By idiopathic contraction with rigidity {cmitrnriure of 
the French writers), is meant the involuntary tonic contraction of differ- 
ent flexor muscles of the extremities, particularly those of the fingers and 
toe?, but .sometimes of the forearms and arms also, existing independently 
of any appreciable organic disease of the cerebro-spinal axis. It has 

' Dr. J. Lewis Smith {op. eit, p. 199). 



568 CONTRACTION WITH RIGIDITY. 

been described by different English writers in connection with laryngis- 
mus stridulus, under the title of " carpopedal spasms," " cerebral spas- 
modic croup," " croup-like convulsions," etc., etc. We believe, however, 
that it will be useful to describe it separately from that disorder, for 
though of the same nature, and sometimes associated with it, it often exists 
as an independent aifection. 

Causes. — It is most common between the ages of one and three years. 
It is much oftener sympathetic than essential, and its most frequent causes 
are dentition, disordered states of the digestive function dependent upon 
improper alimentation, anaemia and its accompanying nervous excitability, 
brought about by digestive and nutritive derangements, pneumonia, bron- 
chitis, masturbation and other forms of irritation of the genitals, and un- 
favorable hygienic conditions. In some few cases, the disease is truly 
essential, since no pathological cause for it whatever can be detected. It 
is merely necessary to say that it is also often symptomatic of disease of 
the brain, but of that form of the affection nothing will be said in the 
present article. 

Nature of the Disease. — It appears to consist in a functional de- 
rangement of the motor tract of the cerebro-spinal axis, occurring with- 
out any cause that can be detected, or determined by the existence of 
some irritation affecting incident excitor nerves. We once saw a child 
two years of age, who, after a restless, uneasy night, presented in the 
morning tonic contraction of the flexors of all the toes of both feet, so 
that the insteps were swelled, and looked smooth and polished. There 
was no other sign of sickness except peevishness. Learning on inquiry 
that the bowels had been somewhat constipated for several days, and that 
the materials of the scanty stools which had been discharged were dark- 
colored and very offensive, we ordered a dose of castor oil containing two 
grains of calomel. The contraction continued unyielding until six o'clock 
in the afternoon, when a very copious, dark-colored, viscid, and offensive 
stool occurred, and the contraction immediately ceased. Here the cause of 
the contraction was evidently an accumulation of unhealthy fecal matter 
in the intestine, which, by irritating certain sensitive fibres of the excito- 
motory system, caused a reflex motor action that gave rise to permanent 
muscular contractions. In other cases the disturbance of the excito- 
motory system depends on the reflex irritation occasioned by the process 
of dentition, by indigestion, by diarrhoea, pneumonia, pleurisy, etc. In 
other instances, again, to which the term essential must be applied, it 
seems to depend simply on general debility and anaemia, which are well 
known to be productive of functional disease of the nervous system. 

Symptoms; Course; Duration. — The disease rarely attacks children 
previously in good health, but generally those already suffering from some 
disorder of the general health, or a severe local affection. When sympa- 
thetic, the first symptom noted is the contraction which constitutes the 
disease. When essential, on the contrary, the onset is sometimes marked 
by various nervous symptoms, such as giddiness, headache, or somnolence, 
which soon pass off, leaving the simple contraction with rigidity as the only 
morbid condition. In most cases, however, the attack begins with the mus- 



I 



SYMPTOMS — COURSE — DURATION. 569 

cular contractioD, which generally affects the superior extremities first, and 
gradually extends to the inferior. 

When the disease is fully developed, the thumbs are drawn down into 
the palms of the hands, and the fingers, strongly flexed at tlie metacarpo- 
phalangeal articulations, cover and conceal the thumbs. At the t^nme time 
that the metacarpo-phalangeal articulations are flexed, the phalanges them- 
selves remain extended and the fingers are separated from each other. The 
contraction genemlly afiects the wrist-joints al:?o, so that tlie hands are 
strongly flexed upon the fouearras, and in some rare cases the latter upon 
the arms. The disorder usually affects the inferior extremities likewise, the 
toes being in a state of tonic flexion or extension, the foot rigidly extended 
upon the leg, and its point sometimes drawn inwards. The spasm very 
rarely extends to the knees. 

Children old enough to describe their sensations generally complain of 
stiflhess in the affected parts, with more or less severe pains darting along 
the course of the nerves. The contracted muscles are hard and rigid to 
the touch, and sometimes enlarged so as to appear in strong relief under 
the skin. In slight cases the contractions can be overcome by very moder- 
ate force and without pain, whilst in those which are more severe, the at- 
tempt to overcome the contraction is productive of acute pain in the rigid 
parts. The backs of the hands and the insteps present a swollen appear- 
ance, and the skin over these points is smooth and polished. In the case 
communicated by Dr. Benedict, appended to the article on laryngismus 
stridulus, and likewise in our own case, the skin under the thumbs had 
assumed the appearance of mucous membrane, from the long and close 
confinement of the member. 

In addition to the symptoms already enumerated as characteristic of the 
malady, there are others which require attention. The child is of course 
unable to walk or perform any prehensile movement. The intelligence 
and senses always remain perfect in simple, uncomplicated cases. The 
nervous system shows signs of disorder in the form of restlessness or lan- 
guor, and irritability, with crying and peevishness. In the great majority 
of instances, these are the only nervous symptoms, though in some there 
are general or partial convulsions, strabismus, and diminution of sensi- 
bility. Of these the most frequent are convulsions, which generally come 
on a few days after the attack, or precede the fatal termination. In the 
case of Dr. Benedict, referred to above, there were occasional choreic 
nioveraeuts of the face, arras, and body. The simple disease is unaccom- 
panied by any febrile movement, and the organic functions go on naturally. 
In the sympathetic form, on the contrary, we have the various symptoms 
of the disease which acta as the cause of the contraction, whether that be 
abflominal or thoracic. The most common train of symptoms, in young 
children, is the same as that which accomjianies gastric or intestinal de- 
rangement, morbid dentition, etc. The course and duration of the disease 
are very irregular and uncertain. When once developed it may last from 
weeks to months, either slowly increasing in severity, or remaining station- 
ary for a length of time. As a general rule, after it has lasted for some 
time, it becomes intermittent, sometimes diminishing or even disappearing 



570 CONTRACTION WITH RIGIDITY. 

entirely for a period, then reappearing or increasing, to subside or cease 
again, and so changing without regularity or evident cause, until at last 
recovery gradually takes place, or death occurs from the concomitant dis- 
ease, or in a paroxysm of convulsions. 

Diagnosis. — The only difficulty in the diagnosis of idiopathic contrac- 
tion is to distinguish it from symptomatic contraction, or that which 
depends upon cerebral or spinal disease. The kinds of cerebral disease 
which most frequently occasion contraction are tubercle of the brain, and 
meningeal haemorrhage. The distinction can generally be made with con- 
siderable facility, however, by attention to the various disorders of intel- 
ligence and sensibility, to the fever, constipation, vomiting, and different 
modes of invasion and progress which characterize the symptomatic form. 
The following table, taken from MM. Rilliet and Barthez, will assist in 
the diagnosis. 

SYMPTOMATIC CONTRACTION. ESSENTIAL CONTRACTION. 

Cerebral symptoms, special functional Similar cerebral symptoms, but only 

disorders (convulsions, strabismus, dila- in exceptional cases, sometimes accom- 

tation of the pupils, etc.), preceding or panying, but never scarcely preceding 

accompanying the contraction. the contraction. 

In many cases irregularity of the pulse. No irregularity of the pulse. 

Generally partial, and commencing Binary, commencing in the fingers 

usually in the elbows and knees, and in and toes. 
a single extremity. 

Almost always permanent. Eemarkably intermittent. 

Prognosis. — The prognosis must depend on the cause of the malady. 
The contraction itself has no influence whatever on the termination. The 
fatal termination has always resulted from the anterior or concomitant 
disease. Six cases observed by M. Barrier all recovered. The case com- 
municated to us by Dr. Benedict, which was connected with laryngismus 
stridulus, and one very severe one that occurred in our own practice, also 
terminated favorably. The prognosis is favorable, therefore, when the 
attack occurs in a child of naturally good constitution, and when the cause 
of the disease is not a permanent or incurable one. The possibility of the 
occurrence of fatal convulsions should always lead us to make a guarded 
prognosis. 

Treatment. — The treatment must depend on the circumstances under 
which the disease has made its appearance. When it occurs in the course 
of an acute local affection, the treatment must of course be that which is 
proper for the concomitant disorder. When it depends on dentition, or 
on gastric or intestinal derangement induced by improper diet, the treat- 
ment is the same precisely as that recommended for laryngismus stridulus 
dependent on the same causes. 

It may be stated that, as a general rule, all violent remedies, as bleeding, 
calomel, except in very minute doses as an alterative, drastic cathartics, 
and blisters, can scarcely fail to be injurious, unless manifestly necessary 
in the treatment of the concomitant affection. 

It is proper in almost all cases to combine with the treatment already 



J 



CASE OF CONTRACTION. 571 

recommeuded, the employment of antispasmodic remedies, particularly 
when the contractions persist after the removal of the primary disease. 

The best remedies of this class are the warm hath, used every day ; bel- 
ladonna ; couium ; bromide of potassium ; the fluid extract of valerian ; 
assafa^tida, and camphor. We would further recommend the use of rem- 
edies calculated to improve and invigorate the nutrition, and particularly 
cod-liver oil and iron. The diet ought generally to be nutritious and 
strengthening, particularly when the patient is weak and delicate. 

In conclusion we may state that the treatment should be very much the 
same as that proposed for laryngismus stridulus, and we therefore refer the 
reader to that subject for more detailed information. 

CASE BY DR. J. F. MEIGS. 

Case — The subject of this case was a girl nine months old. The parents were 
healthy persons, but the mother, owing to some idiosyncrasy, had made but a jioor 
nurse for the preceding child, and I had strongly advised her, therefore, at the birth 
of this one, to give it a wet-nurse. This was not done, however, and it was found 
necessary to feed the infant a great deal from its birth. During the early month.s 
of its life it had some slight attacks of disorder of the digestive system, but being 
taken to the country for several months in the summer, it there improved very 
ranch. On being brought back to town I saw it, and found it pretty well devel- 
oped, but very pale, and, on the whole, delicate-looking. It was still nursed by 
the mother, but not to any very considerable extent, as it was obliged to be fed 
several times each day. The food consisted of different farinaceous substances 
made with cow's milk. 

On the left forearm of the child there was situated a congenital aneurism by anas- 
tomosis, which had grown, by the age of nine months, to be as largo as a tivo-cent 
piece. It was deemed necessary to remove this tumor, and, accordingly, on the 
lllh of January, 1852, a surireon tied it with a needle and double liLjature. The 
child bore the operation very well, was soon quieted, and was cheerful and ate well 
until the evening of the loth, when it was attacked with fever, which lasted all 
night, and was accompanied with a good deal of cough and some gurgling in the 
fauces. On the following morning, at about 7^ o'clock, it had a slight convulsive 
seizure, lasting a few moments, and marked by stiffening of the body, and a star- 
ing expression of the eyes. In the middle of the day, it was seized again, and 
during that and the next day (17th), up to 10 p.m., it had twenty-four convulsions. 
These lasted from three to ei:;ht minutes each ; they were general, and consisted 
of flexions of the limbs, working of the face, and were attended with unconsciou.?- 
nes.s. There was no opisthotonos during the attacks, no extensions of the limbs, 
and no contraction of the jaw. Between the seizures, the child nursed perfectly 
well, sucked the finger, had no 6tiffne.«s of the lower jaw, and was perfectly con- 
scious. There was, during these two days, some fever, as the skin was too warm, 
and the pulse between 101 and 180. The respiration was ra(»re frequent than natu- 
ral, there was a good deal of cough, some caturrhal r&les in the chest, and also 
•ome gurgling in the fauces. The stools were scanty, pasty, and white. There was 
a well-marked but rather faint rash on the limbs and trunk, like erythema or mild 
scarlet fever, and the lymphatic glands on both sides of the lower jaw were some- 
what swelled, and quite hard. The treatment directed was one-sixth of a grain of 
calomel every two hours; two drops of solution of morphia with five of fluid ex- 
tract of valerian, to be given also every two hours; warm immorsion baths, and 
mustard fool-baths. On the second day, blisters were applied behind the ears. 

On the 19th, the child was better. There was no convulsion ; she noticed well, 
smiled a little, nursed heartily, and took some arrowrool-watcr. 



572 CONTRACTION WITH RIGIDITY. 

During all this time the tumor in the arm was not at all inflamed. It was 
neither red, sore to the touch, nor swelled. It was suppurating slightly. Under 
the idea that the convulsions might depend in part on the operation, and in order 
to promote suppuration,- a warm poultice was kept constantly applied over the 
tumor. 

The child continued better, with the exception of slight angina and severe cough, 
until the morning of the 22d, when it waked early, crying violently as though in 
severe pain, and I found the fingers of both hands strongly flexed at the meta- 
carpal articulations over the thumbs, which were themselves drawn into the palms 
of the hands. The phalanges, though bent, as just stated, at the metacarpal ar- 
ticulations, were stifily extended at the phalangeal articulations, and at the same 
time separated from each other. The bands were flexed at the wrists. The toes 
were flexed, and the feet stiffly cramped at the ankles, and the insteps, as also the 
backs of the hands, looked swelled and cushiony. Any attempt to open the hands 
was painful and caused crjnng. The pulse was frequent and small, the skin pale, 
and very slightly too warm; the intelligence was perfect. The jaw was open, and 
the act of sucking was performed, but with some difficulty. On the previous day 
the bowels had been opened three times, and on this day once; the stools were 
scanty, pasty, and white. At 9 a.m. I ordered two drops of solution of morphia, 
five of the fluid extract of valerian, and twenty of milk of assafoetida, to be given 
every two hours. 

4 P.M. — Same state, except that the contraction is stronger. There is more heat 
of skin, much crying, and a restless, distressed motion of the head. At 4J o'clock, 
two drops of laudanum were given with assafoetida. A teaspoonful of the follow- 
ing mixture was ordered every hour : 

R. — Mass. Hydrarg., gr. iij. 

01. Kicini, f^iij- 

Syr. Khei. Aroraat., f^v. — M. 

10 P.M. — Has taken three doses of the mixture and had one large, whitish, pasty 
stool. Much easier. Has slept a good deal. Contractions not so strong, as the 
hands can be opened more easily, and with very little pain. Skin soft, of natural 
temperature, and moist. Ordered one or two more doses of the mixture, and a 
repetition of the laudanum and assafoetida, in case of restlessness. During all this 
time the tumor has not separated. A process of ulceration is going on around 
the ligatures, but there is no inflammation of any consequence; the arm is not 
swelled, and there is neither redness nor soreness to the touch. 

January 30th. — The contracture diminished very much for two days, and then 
returned, so that during the 27th, and 28th, and 29th, it was very marked, the fore- 
arms being flexed on the arms, and the hands strongly flexed on the forearms. 
The feet also were very stiff", and strongly flexed. The head was occasionally but 
not constantly retracted upon the trunk. The child evidently suffered very much, 
as it cried constantly and was very restless, except when under the influence of 
anodynes or antispasmodics. The bowels are sluggish, but have been kept open by 
the oil and rhubarb mixture. The dejections were generally whitish and pasty, 
but occasionally there was a healthy yellow stool. On the 28th the following mix- 
ture was ordered : 



R.— Ext. Valerian. Fluid, 



Sp. JEtheris Comp., 
Liq. Morph. Sulph., 
Syr. Tolutan., 
Aquae, .... 
A teaspoonful to be given every hour or two, when there is much suff'ering or J 
restlessness. 



fSJ- 



f^ss. 
gtt. Ix. 

fJij.-M. I 



! 



CASE OF CONTRACTION. 573 

On the evening of the 29th the ligatures were removed, as they had become en- 
tirely loose, though without cutting off the tumor. The diseased point was not 
much inflamed, nor was it very tender. 

The child is still nursed and fed. Since the 29th it has had goat's instead of 
cow's milk. On the evening of the 30th the patient was more tran'^uil, the ex- 
pression was more placid and open, and the contracture not quite so strong. 

Up to February 7th, there was no decided -change in the symptoms. They con- 
tinued quite as severe Jis before. The dyspeptic symptoms, the torpid state of the 
bowels, the want of appetite, and the white, pasty state of the evacuations were 
never relieved, except momentarily, by means of cathartics. On the 7lh a wet- 
nurse was procured, but only after the most persevering and urgent solicitation 
and argument on our part, I having long been convinced that the cause of the con- 
tracture lay in the disordered state of the digestive functions, produced and kept 
up by artificial diet, and perhaps by an unhealthy state of the mother's milk. The 
parents, however, had always thought that the operation had been the cause of the 
convulsive disease, and for a length of time would not consent to a wet-nurse. 

After the child had been suckled by the wet-nurse for two days, the stools, which, 
since the beginning of the sickness, now twenty-three days, and to a greater or less 
extent since birth, had been very unhealthy, became yellow, homogeneous, and 
natural in character ; while the bowels, instead of being obstinately constipated, 
so as to require large doses of cathartic medicine, were moved spontaneously two 
or three times a day. 

On the 10th we noticed strong divergent strabismus, and the child looked very 
badly. The left leg was drawn up, whilst the right was stiffened. The left arm 
was more used than the right, the left hand being carried often to the mouth, while 
this was never done with ihe right. It was difficult to measure the degree of the 
intelligence, but the child occasionally looked at and evidently noticed objects, but 
during most of the time it was dull and inattentive. 

On the 13th there was an evident improvement, the previous night having been 
very good. The face was improved in color and expression, and was not quite so 
thin. The contraction was about the same. 

14th. — Some diminution of the contraction, the forearm being a little extended 
upon the arm, and the wrists, though still very rigid, not quite so much drawn. 
The child looks better; she nurses a great deal, taking all that the mother, and 
most also of what the wet-nurse, a hearty woman, has. 

February 20th. — Doing very well up to last night, when she became more rest- 
less, cried a great deal, rolled the head on the pillow, and had slight retractions of 
the whole trunk of the body. Occasionally she coasod to cry, scarcely broath('<l, 
and the eyes were rolled upwards and fixed for several seconds. She looked pale 
and pinched again, and refused to nurse. Had one whitish, curdy stool. 

2l5t. — Better; more quiet; nurses well. The boring with the head has cea.sed, 
and also the retractions of the trunk. One healthy stool. 

22d. — Much better ; nurses well ; one healthy stool. The contraction of the right 
arm is yielding, and that of the forearm on the arm is gone on both sides. The 
left wrist is straight; the right one is yielding very much, though it is still some- 
what bent The fingers of the right hand, though still bent, have relax<!d very 
much ; those of the left hand arc still very much bent, but arc less rigid than be- 
fore. The integument of the palms of both hands baa become, in the flexures, 
whitish, soft, moist, mucous-like, and has an ofTmsive odor. To-day and yester- 
day the child uses the arms, touches and reaches out for articles; she is much more 
intelligent, and looks at and observes objects ; she now holds her head up, an<l likes 
to be carried about .sitting up in the arms of the nurse, which b«'fore she could not 
do at all. She is gaining flesh ; the color of the surface is improving ; the ears have 
become pink and pretty. 

A fresh assafcelida plaster was applied upon the back yej«terday. 

March Ist. — Continues to do well. The right hand is today almost natural, 



57-1 CONTRACTION WITH RIGIDITY. 

being opened and shut, and used to grasp with, though it still looks a little stiff. 
Left hand much better; she opens and shuts the forefinger, and grasps and holds 
toys with it, but the other fingers are still much contracted. The movements of the 
arms are quite easy and natural. There is no bending of the hands at the wrists, 
except, perhaps, very slightly in the left extremity. The feet are natural, except 
a slight stiffness. She now nurses very well, and is growing fat. She is larger, in 
fact, than before the sickness. The intelligence is improving rapidly, as she no- 
tices, smiles occasionally, and distinguishes, her attendants think, between persons. 
The bowels are regular without medicine. She has taken no remedy of any kind 
for three days past. 

March 11th. — Almost entirely recovered. There is still a slight but only very 
slight flexion of the fingers of the left hand. General health excellent. 

March 29th. — The patient is nov/ perfectly well, except that she uses the forefinger 
of either hand rather better than all together, so that in grasping and holding an 
object, she is more apt to seize it with the forefinger than with all. Still she can 
and does grasp with all, when the object is large, and no one, unless very observant, 
would notice the peculiarity just described. Embonpoint very good; complexion 
clear and healthy ; sleeps sound ; bowels in excellent condition. Intelligence per- 
fect ; smiles and laughs a great deal, and distinguishes between persons ; takes a 
great deal of notice. She is about equal in intelligence to a child of eight months 
old. Does not attempt to speak. 

April 10th, 1852. — I was sent for to-day. The child had not been well for three 
days, having had three or four thin and greenish stools a day, with whitish specks 
in them. She was fretful and did not sleep well, and had a good deal of loose ca- 
tarrhal cough and some acceleration of the breathing. I found her in the morning, 
after a restless night, quite feverish, hot and dry, with frequent respiration, and with 
some catarrhal wheezing in the chest. She had coughed a good deal, and her mother 
had found her hands showing some signs of spasm, the forefingers being extended 
as though pointing, and separated from the other fingers, which were flexed, with 
the thumbs also, into the palms of the hands. 

There is some degree of laryngismus, as on wakjng from sleep the breathing is 
labored, difficult, partially suspended, and accompanied with a slight crowing, or 
rather choking sound, while at the same time the face becomes pale and the mouth 
bluish. Bowels open three times yesterday, the stools being mucous, greenish, and 
containing small lumps of undigested casein. 

Ordered a quarter of a grain of mercury with chalk diffused in a teaspoonful of 
syrup of jalap to be given every two hours. 

At 1 P.M. there was a slight general spasm, with stiffening of the limbs and re- 
traction of the head, lasting, however, only a few moments. This occurred again 
in the afternoon. The dose of the mercury and jalap was reduced one-half in the 
middle of the day, as the quantity first ordered was found to cause sickness and 
vomiting. 

Evening. — Rather better. No fever ; some moisture of the skin ; spasm of the 
hands very much relaxed. The diminished dose of mercury and jalap was well 
borne. 

11th. — Rather better. Some fever still, with cough, gurgling in the throat, and 
distinct enlargement and hardening of the lymphatic glands at the angles of the 
jaw on both sides. There is still some contraction of the hands. Bowels open 
freely twice last night, and the stools better, being of a pale yellow color, and more 
homogeneous. The jalap and mercury to be suspended. 

In the course of the day there were two slight general spasms, with laryngismus. 
The latter occurred several times during the waking state, but was not severe. Or- 
dered three drops of syrup of ipecac, with four of sweet spirit of nitre, to be given 
every two hours. 

12th. — Much better. Contraction of hands almost gone; very slight feverish- 



CASE OF CONTRACTION. 0<O 

ness ; cough loss frequent and looser; respiration easy. No spasm t(»-day. Stools 
more healthy, yellow, homogeneous, and of natural quantity. 

13th. — Continues better. Contraction slight. Cough diminishing very much. 

14th — Rather pale, dull, and languid. Has hud several attacks of laryngismus, 
one of which was quite severe, being attended with deep blueness about the mouth, 
and some of the face also. Does not nurse so well as formerly. The hands exhibit 
decided tlexion of the third, fourth, and fifth fingers at the metacarpo-phalan- 
geal articulations, with stiffened extensiim of the other phalangeal articulations. 
Thumbs slightly drawn into the palms, and the ft>refingers rather extiuded. 
Bowels natural. Ordered fifteen drops t)f brandy, and a very small pinch of the 
Quevenne's metallic iron in powder, three times a day. 

loih. — Condition about the same. On the 2'2d of March, the first wet-nurse, 
under whose charge the child had improved so rapidly, was changed, on account 
!' some objection to her personal appearance, and another one procured in her 
J lace. This one was a healthy-looking woman, with milk enough, but she was 
red-haired, irritable, and excessively high-tempered, and the child has been losing 
ground ever since her arrival. Under the idea that her milk did not suit the 
child, a third nurse was by my advice obtained to-day (loth), a calm, placid, fat, 
and comfortable-looking woman, with an abundant supplv of milk of ten months 
old. 

17th. — The child has improved very much She is fatter already, has a contented, 
tranquil expression, t«kes more than she did from the previous nurse, and njects 
much less of the milk. The stools are now regular, occurring twice daily without 
aid, and of a natural appearance. The sleep of the child is better now than it has 
been at any lime since the first wet-nurse was dismissed. The attacks of laryngis- 
mus are already much less frequent, and less severe. The hands are very nearly 
n a natural condition. The child is less nervous, not starting now as formerly at 
zjunds. 

To continue the brandy and iron. 

From this period the child continued to improve regularly in health. She was 
removed to the country during the summer months, and when brought back in 
the autumn, was entirely well, with the exception that she was less forward in 
walking than mc»st children, but not more so than might have been expected in 
one who had been dangerously ill for so long a time. Her intelligence was good 
in all respects. 

February 6th, 1853. — We have seen this child to-day, and find her in very good 
health, except that she is rather smaller in size than is usual at her present ag<'. 
^he has been weaned now fi.»r alnjut six weeks, and eats heartily and digests well 
most ordinary f«x)d, as milk, meat, potatoes, etc. The weaning was borne very 
well, except that the appetite was rather deficient and capricious, for about a woi-k 
after the departure of the nurse. .She can stand up when placed in the erect posi- 
tion, and can walk feebly when well 8upfK>rted, but not alone, nor can she rit^e up 
from a sitting posture. Her intelligence i."*, in all respects, perfect, but «he does not 
talk as yet. There is no vestige of her former sparmfxlic symptoms, when she is in 
good h«nlih ; but any little turn of sickness reproduces some contraction of one b-g, 
and a >lig1it flexion of the hands. 

Some months after this, the child was unfortunately seized with hooping-cough. 
■^he did well for several weeks, but one day, being seized with a fit of coughing 
while t<'nied upon the floor playing, died instantly, doubtless-from asphyxin, caur«pd 
by Complete closure of the glottis by »|»asm. This i» the only case of booping-<'ough 
that we have ever known to prove suddenly fatal in this way. There ii» every reason 
to »uppo»e that the fatal suspension of rcnpiraliou was caui^ed by the unnatural ex- 
citability of the sphincter muscle uf the glottis, left by the previous attack of 
laryngismus stridulus. 



576 TETANUS NASCENTIUM. 



ARTICLE IX. 



tetanus nascentium. 

Definition ; Synonyms ; Period of Occurrence ; Frequency. — 
Tetanus nascentium is a most fatal affection, occurring principally during 
the first two weeks after birth, usually running an acute course, and char- 
acterized by a more or less general tonic contraction of the voluntary 
muscles, with paroxysmal exacerbations, and usually without any period 
of complete relaxation until the close of the malady. 

From this definition it will be seen that the affection does not differ in 
its essential nature from tetanus as it occurs in adults ; though there are 
so many peculiarities in its causes and symptoms as to demand a special 
discussion. This disease has also been described under the names of tris- 
mus nascentium or neonatorum, in accordance with the prominence and 
frequency of contraction of the muscles of the lower jaw; but as the spasm 
is rarely limited to these muscles, but usually involves the other muscles 
of the face and those of the extremities, the more comprehensive name of 
tetanus seems more appropriate. It most frequently makes its appearance 
between the third and tenth days after birth, although there are cases on 
record in which it set in fifteen hours after birth (West), and others where 
it did not manifest itself until the twelfth or fifteenth day. 

Causes. — The causes which have been assigned for the production of 
tetanus nascentium are very numerous ; they may, however, be generally 
divided into tlie groups of general and local. Among the local causes, the 
various morbid conditions of the umbilicus and umbilical vessels hold the 
most prominent place. These are, however, far from being constantly 
present, and yet the weight of evidence is at present in favor of regarding 
diseases of the umbilicus, and more especially of the umbilical arteries, 
as occasional causes of tetanus nascentium. 

In other cases, the disease has been attributed to some blow or accidental 
injury which the infant had received. It is, however, still a vexed ques- 
tion as to how much influence should be ascribed to those purely mechan- 
ical impressions in the production of this affection. One of the most 
powerful efforts yet made to establish their importance was by Dr. Marion 
Sims,^ who published a series of articles to prove that " trismus nascen- 
tium is a disease of centric origin depending on a mechanical pressure 
exerted on the medulla oblongata, and its nerves ; and that this pressure 
is the result, most generally, of an inward displacement of the occipital 
bone." This displacement is physiological during the parturient state, but 
its persistence after birth is dependent, according to his theory, chiefly 
upon the improper position in which infants are allowed to lie, resting 
upon their occiput for days together. 

1 Amer. Jour, of Med. Sci., April, 1846, p. 363; July, 1848, p. 59; and October, 
1848, p. 355. 



GENERAL CAUSES. 577 

Further experience, however, has uot confirmed this view, nor justified 
the admission of injury to the cmnial bones into the list of common 
causes ; and yet there are a few cases on record in which tetanus un- 
doubtedly appears to have been developed from this source. 

Gexeral Causes. — Vicissitudes of temperature appear to favor the 
development of tetanus', since it is frequent in many countries where a 
hijih temperature during the day is succeeded by great cold during the 
night. In the same way, exposure of the infant to wet and cold, as by 
putting damp clothes upon it, may be productive of the disease. The 
most frequent and well-established cause of tetanus nascentium, however, 
is a vitiated state of the atmosphere ; whether engendered by a filthy con- 
dition of the bedding or house, or by imperfect ventilation; and it is to 
this that we must attribute the frequency of the affection in such dissimilar 
localities as the Western Hebrides, Iceland and the neighboring islands, 
Minorca (see Cleghorn, Obserr. on Epidemical Diseases of Minorca, London, 
1768, p. 81), and some of the Southern States of America, where it was 
formerly not at all unusual for 50 per cent, of all infants born to perish 
during the first two weeks from this cause alone. It was formerly sup- 
posed that certain localities, pre-eminent among which are those just men- 
tioned, were peculiarly favorable to the development of this disease, but 
it is probable that no predisposition exists excepting the fluctuations of 
the climate and the filthy habits of the people. 

The very great importance of filth and deficient ventilation .as a cause 
of tetanus nascentium is, however, most forcibly shown by the great reduc- 
tion in the frequency of this disease in large lying-in asylums, effected by 
the introduction of more thorough ventilation and a greater regard to 
cleanliness. This was conclusively demonstrated in the Dublin Lying-in 
Asylum towards the close of the last century. Previously to the year 1782, 
of 17,650 infants born alive in the asylum, 2944, or almost one-sixth, had 
died within the first fortnight, and in almost every one of these the cause 
of death was tetanus nascentium. During the next seven years, after Dr. 
Clarke had simply introduced a much more complete system of ventilation 
in the wards, of 8033 children born, only 419 in all died, or about 1 in 19, 
or 5ith per cent. 

Our comparative immunity in this part of America, even among the 
ji r in our cities, is probably due to the greater degree of cleanliness in 
tilt ir houses, and to the improved construction of our hospitals and 
a.sylums. In New York, however, according to Dr. Smith,' there are more 
»!• aths from tetanus during the first year of life than at all other ages 
I _ ther. 

The mortality returns of this city indicate that tetanus, although com- 
' paralively frequent among infants, is much lam so than in New York. 

Thus during the 9 years from 1860 to 1868 inclusive, the returns show 
a total mortality fless still-born), at all ages, of 127,563, and under 1 year 
of 36,765. During this period there were 233 deaths from tetanus at all 
BL'.-; 61 of which were during the first year of life, and 157 after that 

> Amcr. Jour, of Med. Sci., July and October, 1866; and op. cit., p. 168. 
I 87 



578 TETANUS NASCENTIUM. 

age. Thus the proportion of deaths from tetanus to those from all causes 
was, after the age of one year, as 1 to 598, and during the first year of 
life, as 1 to 602. 

During this same period, the number of births in Philadelphia amounted 
to 146,895. 

Pathological Appearances. — We have already alluded to the mor- 
bid conditions of the umbilical vessels or umbilicus occasionally found in 
tetanus uascentium ; it is evident, however, that if these lesions have any 
connection with the disease, they merely act as exciting causes. 

The only characteristic lesions of this affection are presented by the 
nervous system. 

The brain and its meninges are frequently found intensely congested, 
though this is not so uniformly present as a similar condition of the spinal 
cord; according to numerous observers, however, it is more frequently 
present than absent. In some cases, this congestion has led to an actual 
effusion of blood, either between the skull and dura mater, into the arach- 
noid cavity, or into the ventricles. In some cases, instead of haemorrhage, 
there has been found serous effusion into the ventricles or into the sub- 
arachnoid space, accompanied with a diminution of consistence of the cere- 
bral substance, as reported by Matuszynski. 

The morbid appearances found in connection with the spinal cord are 
the same in character as the above, but more constant and even more 
marked. The vessels of the spinal meninges and of the substance of the 
cord are intensely congested, and there is frequently effusion of blood into 
the cavity of the arachnoid. 

The value of these appearances was formerly underestimated from a sus- 
picion that they might be partly, at least, due to the mere gravitation of 
the blood after death. This suspicion has, however, been entirely re- 
moved by the observations of Weber of Kiel, and Finckh of Stuttgardt, 
who placed the bodies of infants dying with tetanus in various positions 
before examining them, and yet invariably found the above-mentioned con- 
ditions. 

There is, however, a further source of doubt as to the significance of 
these lesions. We have already seen, in speaking of eclampsia, an affec- 
tion in which no appreciable material lesion has as yet been detected, that, 
in a certain proportion of cases, congestion, serous effusion, or actual haem- 
orrhage might be present not as causes but as effects, and due merely to 
the intense venous engorgement caused by the embarrassment of the respi- 
ration and venous circulation during the convulsion. It is, indeed, it seems 
to us, highly probable that a similar interpretation may be placed, in many 
cases at least, upon the morbid appearances above mentioned as being 
found after death from tetanus nascentium. 

We have thus enumerated the lesions of the nervous system which are 
readily discoverable in many fatal cases of tetanus; and yet these lesions 
are, it will be observed, almost without exception concerned merely with 
the vascular supply of the brain and spinal cord, and we are as yet with- 
out any accurate investigations into the condition of the nervous tissue 
itself. Within the past few years, the wonderful advances of microscopi- 



SYMPTOMS. 579 

cal science, as applied to pathological anatomy, have revealed structural 
changes in the nervous system in connection with more than one disease, 
whose pathology has heretofore been utterly obscure, and it is not too much 
to hope that at no distant period the question of the presence of any defi- 
nite structural change in the brain or spinal cord in cases of tetanus nas- 
centium will be positively settled. In connection with this suggestion, 
especially in consideration of the analogy between this disease and tetanus 
in the adult, we append the results of the investigations of Rokitansky and 
Demme upon the microscopical appearances in the si)inal cord in fatal 
cases of this latter affection/ 

1. The constant anatomical character of tetanus appears to be prolifer- 
ation of the connective tissue (of the cord); the most striking peculiarity 
of this lesion is the extent over which it is found. 

2. The product is a viscous mass, abounding in nuclei; it remains at this 
stage of development in both acute and chronic cases, never progressing to 
the formation of fibres. 

3. This change is found almost exclusively in the white medullary sub- 
stance ; the gray matter seems to suffer only secondarily, and then from 
compression rather than interstitial deposit. 

4. The proliferation is not always followed by corresponding swelling of 
the white matter ; it can often be recognized only by means of the micro- 
scope. 

5. It was principally found in the medulla oblongata, the crura cerebri, 
the inferior peduncles of the cerebellum, and in the greater part of the 
spinal cord. 

6. This lesion of the connective tissue appears to be due to long-contin- 
ued or repeated congestions. 

7. The |)eriod at which it occurs probably varies in different cases. 
These observations, which were originally published about 1860, have 

V>een confirmed in all essential particulars by Wagner (Syd. Soc. Year-Book, 
1862, p. 219) ; and still more lately by J. Lockhart Clarke, who published 
in the Med.-Chir. Tram., vol. xlviii, the results of the microscopic examin- 
ation of the spinal cord in six ca.«es of tetanus, in all of which structural 
i' -i'-ns were discovered ; and by Dr. Dickinson {Med.-Chir. Tratin., vol. li, 
p. -2^)0). 

Symptoms. — There are rarely any premonitory symptoms of the attack, 
but the onset and development of the disease are usually gradual. The 
earliest symptom noticed is, in most ca.ses, difficulty in nursing ; the infant 
ipp<*aring anxious to nurse and eagerly pressing its mouth against the nip- 
ple, but being unable to fully take it into the mouth or to suck, from a 
rigid condition of the raa-sseter muscles. At the same time it utters a 
whimpering, whining, unnatural cry. 

The tonic muscular contraction very rarely remains limited to the mas- 
-eters, but soon invades the other muscles of the face, and those of the 
trunk and extremities. 

The expression of the face thus produced is indicative of great suffering ; 

> Schmidt's Jabrb., vol. tii pn New Syd. Soc. Year-Book, 1864, p. 232j. 



580 TETANUS NASCENTIUM. 

though it is impossible to say how truly this represents the sensations of the 
patient. 

The face is drawn into wrinkles and furrows, and has a strange appear- 
ance of age. The condition of the mouth, however, is most characteristic ; 
the jaws are firmly fixed, the lips slightly separated and pressed firmly 
against the gums, and the angles of the mouth drawn backwards and down- 
wards in the well-known risus sardonicus. 

During this time, the other voluntary muscles gradually become rigid. 
At first, their contraction can be overcome by the use of a moderate de- 
gree of force, but in the course of twelve or twenty-four hours the period 
of maximum rigidity is attained. The head is drawn backwards, and 
firmly fixed ; the arms are flexed, and the hands clenched, with the thumbs 
drawn across the palms. The thighs may be flexed upon the pelvis, or the 
legs crossed ; the great toes are usually adducted and separated from the 
rest, which are flexed. 

The contraction of the dorsal muscles frequently produces opisthotonos ; 
and the entire body is at times rendered so rigid that it can be raised, with- 
out bending, by placing a hand under the heels and head. This extreme 
degree of spasm of all the voluntary muscles may never be developed in 
some cases ; or, when present, it often is not so persistent. When the infant 
is quiet or sleeping, there is usually a certain degree of relaxation. It is 
a marked peculiarity of the aflection, however, that exacerbations of the 
tonic spasm are produced by the slightest exciting causes, as an eflfort at 
deglutition, a sudden noise, a puff of air, the most delicate touch, or even 
the alighting of a fly upon the surface. During these paroxysms or clonic 
spasms, the muscular rigidity and contraction attain their greatest height, 
and produce the most painful distortion of the face and limbs. The fit, 
according to West, may be ushered in by a screech. During its continu- 
ance, there is serious interruption of respiration and circulation ; the sur- 
face becomes livid, and epistaxis may occur. It is during this condition, 
too, that haemorrhages- into the brain or spinal cord, or their meninges, 
may result. 

These paroxysms recur at irregular intervals, but usually, in fatal cases, 
occur with increasing frequency until either the child expires suddenly 
during one of the fits, or passes into a state of coma. 

The pulse does not present any characteristic change ; in some cases it 
has been found accelerated, but in others has continued normal, or has 
even fallen below the healthy rate. 

The condition of the bowels is not uniform. Diarrhoea is frequently 
present, but is probably due to irritation of the bowels from the irritating 
nature of the ingesta, or to some accidental cause ; particularly as the 
bowels are occasionally constipated in well-marked cases. 

The appetite generally appears to continue, but we have already alluded 
to the fact that any attempts to feed the child bring on violent spasms, 
which expel the greater part of the food taken into the mouth. Owing 
principally to this obstacle to the nourishment of the infant, the emaciation 
is more rapid and marked in this than in almost any other affection of 
infancy. 



PROGNOSIS — DURATION — PREVENTION AND TREATMENT. 581 

The state of the pupils in tetanus nascentium has not been noted \vitli 
sufficient frequency or accuracy to aHow any deductions to be drawn with 
regard to it. Smith has seen the pupils contracted in the last stage of the 
disease. 

Prognosis. — The majority of authors state that they have never met 
with a case of recovery from fully established tetanus nascentium. 

Dr. Smith has, however, collected 8 cases of recovery, in the histories 
of which he calls attention to two important peculiarities ; that the chil- 
dren were all about a week old when the initiatory symptoms appeared, 
and that there were fluctuations in the symptoms of the disease. The only 
circumstances, then, which would lead us to form a less gloomy prognosis 
than usual, are the late appearance of the disease, and the mildness and 
intermitting character of the symptoms. 

Dr. Hiittenbrenner (quoted in Bo.'ifon Med. and Surr/. Jour., Feb. 12th, 
1874) has lately published the results of more recent clinical experience 
in regard to this disease, from which it appears that although the prognosis 
is very unfovorable, it must not be considered absolutely fatal. 

The dioffuosis of this affection presents no difficulties, being readily made 
by attention to the persistent muscular contraction, the inability to suck 
or to take food, and the exacerbations which are produced by the slightest 
causes. 

DrRATiON. — In fatal cases, the duration rarely exceeds forty-eight or 
>eventy-two hours, and death frequently occurs during the first day. There 
are instances, however, in which its course has been prolonged to the sixth, 
or even the ninth day ; and Smith refers to two remarkable fatal cases, 
recorded by Underwood and Elsiisser, in one of which the duration was 
six weeks, and in the other thirty-one days. 

Dr. Wells has reported (Brit. Med. Jour., Dec. 2l8t, 1861) the follow- 
ing ca.ae of chronic trismus: The child died at the age of one year — hav- 
ing been, from its birth, in a state of tonic spasm or trismus ; it was always 
restless, and appeared ill nourished, though there was no reason for this. 
All treatment was unavailing. It was suggested that the child's state 
might proceed from irritation due to the mother's milk ; and the child was 
wpf\nerl, but without benefit. At the post-mortem examination, there was 
fuiiiid a considerable opalescent eflTusion over the surface of the brain ; the 
cerebellum was harder than usual, and on being cut into presented a homo- 
geneous appearance. The arbf)r vita? was entirely wanting. 

In favorable cases, the duration varies from a few days to one month, or 
even more. 

In the 8 favorable cases collected by Smith, the duration was, in 1 case, 
two days; in 1, a few days; in 1, fourteen days; in 2, fifteen days ; in 1, 
twenty-eight days ; in 1, thirty-one days ; and in the remaining case, about 
five weeks. 

Pp.Er\*ENTToy AND TREATMENT. — It is fortunate that we can by wise 
hygienic measures do much to prevent the occurrence of a disease of such 
fatality, and in which, when once fully developed, treatment is so unavail- 
ing. We have already alluded to the vast diminution in the number of 
deaths from this disease, which followed the introduction of free ventilation 



582 TETANUS NASCENTIUM. 

and cleanliness into the wards of the Dublin Lying-in Hospital. Nor are 
the good effects of this practice limited to public institutions, but it has 
been found that wherever the disease has prevailed to ^ny extent, as on 
the Southern plantations, its progress can be arrested by insisting upon the 
observance of cleanliness in bedding and clothing, of mother aud child ; 
by cleaning, disinfecting, and freely ventilating the houses ; by care in 
dressing the umbilical cord ; and, finally, by attention to the food of the 
infant, and the condition of its bowels. 

Even when the disease has made its appearance, these same measures 
should be carried out with equal care, since by removing all possible causes, 
so far as we are acquainted with them, we may mitigate the severity of the 
attack. 

In addition to the removal of the causes, the strictest quiet should be 
enjoined, and all care employed to avoid exciting the violent paroxysms, 
which are so readily induced. 

It would be well, in addition, to examine the occipital region, to dis- 
cover if the occipital bone be unnaturally depressed, since in one or two 
cases this has appeared to act as the exciting cause of the attack. If such 
depression be found, the position of the child should be varied by placing 
it on its side, in accordance with the recommendation of Dr. Sims. 

The application of leeches to the nape of the neck or along the spine, 
appears indicated in the early stage of the disease. Dr. West advises the 
practice, though he has had no experience in its use. Collins, however, 
states he has tried frequent leeching aloug the spinal column, without the 
least benefit. 

Purgatives are only useful to the extent of maintaining regular action 
of the bowels. 

The remedies which have been most highly recommended as directly 
curative, are ether and chloroform, and various narcotics and antispas- 
modics, as opium, hydrate of chloral, belladonna, aconite, cannabis Indica, 
conium, woorara, tobacco, and assafoetida. 

Anaesthetics have been employed frequently in tetanus of the adult, and 
occasionally in the affection under discussion. Despite, however, the great 
expectations which were entertained in regard to their utility, their action 
cannot be considered directly curative. They relieve suffering, however, 
and by temporarily allaying the spasmodic contraction of the muscles, 
enable us to administer food or remedies, and thus prolong life, and give 
time for other agents to act. " So long, therefore, as the patient is able to 
take food and to obtain periods of comparative quiet, the use of anaesthetic 
inhalations is not desirable. Great advantages may, however, be obtained 
from them if he be unable to open the jaw sufficiently to permit of taking 
food, or if the tetanic spasms are without remission. Ether appears to 
have stronger facts in its recommendation than chloroform." (J. Hugh- 
lings Jackson, and Hutchinson's Report on Tetanus, Med. Times and Gaz., 
April 6th, 1861.) 

The evidence in regard to the superior efficacy of any particular nar- 
cotic, is highly conflicting. Opium has, until recently, been the one 
usually relied upon, and several recoveries have occurred under its use. 



PREVENTION AND TREATMENT. 583 

Of late yeai*s, however, various other narcotics have been emjik^yed, 
especially in traumatic tetanus in the adult. Thus belladonna and its 
alkaloid atropia have been used, the latter hypcKlerniically, with occasional 
good results. If the sulphate of atropia is used hypoderniically in infants, 
the first dose should not exceed the sijjth or t.' jth of a grain, so that its 
effects may be tested carefully. One-half grain of the salt may be dis- 
solved in a tiuid ounce of water, and four to six drops injected under the 
skin along the spine. 

The various preparations of cannabis Indica have also been extensively 
used. Dr. Gaillard reports two cases of recovery from tetanus nasceu- 
tium under this treatment; in one of which the infant, aged eight days, 
took as much as f5ss. of tincture of cannabis Indica in a single day — 
being equivalent to about eleven grains of the pure extract. This quan- 
tity, however, appears excessive. 

Woorara has been given in twenty-two cases, according to Demme, with 
eight cures. It has been recommended by Harley, Spencer Wells, Broca, 
Vella, Chassaignac, and others. The dose in which this poisonous sub- 
stance has been given, is from one-eighth to one-half a grain to an mhtlt. 
The great objection, however, to both this remedy and cannabis Indica, is 
the great want of uniformity in the strength of their preparations, which 
necessitates the utmost caution in their use. 

More recently still, oumerous cases of tetanus in the adult have been 
treated with the various preparations of conium, and with its alkaloid 
conia, and also with hydrate of chloral, and the results have been of a 
decidedly encouraging character. Hiittenbrenner (he. cii.) especially 
recommends hydrate of chloral, which, according to his observations, is 
preferable to all other remedies in this disease. 

Among the antispasmodics most frequently used, are assafretida and 
tobacco, either given internally or by enema, or added to a warm bath. 
There is no very positive evidence, however, of their eflSciency in this 
disease. 

Baths, either of warm water or vapor, should be repeatedly given ; they 
tend to act favorably as sedatives, by relaxing the muscular spasm, and. 
in addition, excite the action of the skin. 

The free u.<e of large doses of (piinine, usually in combination with one 
of the narcotics above mentioned, appears to be serviceable in traumatic 
tetanus, by reducing the frequency of the pulse and mitigating the tendency 
to spasm, so that the induction of cinchonism in tetanus nascentium is a 
measure worthy of a fair trial. 

The application of ice to the spine has been highly recommended in 
tetanus in adults, and is reported to have been used with success in sev- 
eral cases. The condition of the blowl vessels of the cord and its mem- 
branes, in fatal cases of tetanus nascentium, would certainly appear to 
indicate its use in this affection also. 

"Whichever of the above plans of treatment may be adopted, it mu.st 
never be forgotten that one of the principal dangers and most frequent 
causes of death in this disease, is the obstacle offered to the nourishment 
of the infant. We must pay attention, therefore, to the administration of 



584 CHOREA. 

milk, meat-broths, and alcoholic stimuli in small quantities, but frequently 
repeated ; and if the rigidity of the jaw and the occurrence of spasms 
upon every attempt at deglutition, prevent the child from taking food, we 
should have recourse to amesthetics to relax the spasmodic muscular con- 
traction, and enable us to get nourishment into the stomach. 



ARTICLE X. 

CHOREA. 



Defixition ; Synonyms ; Frequency. — Chorea is a non-febrile, con- 
vulsive disease, characterized by irregular and imperfectly co-ordinated, 
but not completely involuntary contractions, of different parts of the mus- 
cular system, and particularly of the muscles of the face and of the ex- 
tremities. 

It is called also St. Vitus's dance, chorea sancti viti, choreomania, epi- 
lepsia saltatoria, and by various other titles. 

It is evidently impossible at present to determine the frequency of chorea, 
as it rarely proves fatal, and consequently scarcely figures in the mortality 
reports. It must, however, be quite frequent, since it rarely happens to us 
not to have several cases under treatment at any one time, either in private 
practice or in some public institution. M. Rufz states (Diet. d'e. Med., t. 
vii, p. 544), that of 32,976 children admitted into the Children's Hospital 
of Paris in ten years, only 189 were affected with chorea, or 1 in 377. 

Predisposing Causes. — Age. — Chorea very rarely occurs during in- 
fancy. According to M. Rufz, it is seldom met with between one and six 
years of age, since of 189 cases, in only ten did it occur within that period ; 
while between six and ten years of age it is much more common (61 in 
189 cases) ; and between ten and fifteen years still more so (118 in 189). 

M. See, in a valuable essay on chorea {Mem. de VAcad. Nat. de MedecifiCy 
t. XV, p. 373), and the relations of rheumatism and diseases of the heart 
with nervous and convulsive diseases, states (page 448), that of 531 cases 
of chorea treated in the Children's Hospital at Paris, during a period of 
twenty-two years, 28 were under six years, 218 between six and ten years, 
and 235 between six and fifteen years of age. M. See concludes, after care- 
fully sifting the facts, that the true maximum of frequency is comprised 
between six and eleven years of age, and that it corresponds especially to 
the tenth year. Under six years of age it becomes more and more rare 
as we approach the moment of birth. MM. Simon and Constant, how- 
ever, met with it in nursing children of twelve, six, and four months of 
age. 

The statistics furnished by Hillier ^ confirm these statements in every 
detail. Thus, of 422 cases treated as out-patients at the Children's Hos- 

1 Diseases of Children (Amer. ed., 1868, p. 234). 



PREDISPOSING CAUSES. 585 

pital in Loudou (where no patients over twelve years are received), the 
numbers at difterent ages were as follows : 



rora 3 


months 


to 6 


monlhs, 


. 3 


" 6 


(( 


12 


t( 


. 5 


'« 12- 


(( 


18 


(< 


o 


«* 18 


(( 


2 


years, 


4 


•• 2 


years 


3 


a 


G 


" 3 


t( 


4 


u 


, 11 


•' 4 


iC 


5 


ti 


, 20 


" 5 


(1 


6 


(( 


, 30 



rom G y 


oars 


to 7 


years, 


. 48 


u - 


(( 


8 


t( 


. 51 


" 8 


u 





(( 


. 68 


" 9 


(i 


10 


(( 


. 80 


'• 10 


It 


12 


(t 


. 104 



422 



or 10S4 cases of ail kinds treated in the wards of the Children's Hos- 
pital of this city during the period of twenty years ending with the close 
of 1875, there were ^o cai^es of chorea. The ages of these were as follows : 

Under 5 years, . ... 2 At 11 years, .... 8 

At 6 years, .... 7 " 12 •* .... 

•♦■ 7 " .... 5 " 13 " .... 4 

'• 8 " .... 6 «' 14 " .... 2 

" 9 " .... 7 " 15 " .... 1 

" 10 " . .14 



Sex. — It is much more frequent in girls than boys. Of the Ool cases 
cited by M. See, 393 occurred in girls, and only 138 in boys. This is the 
same result as that attained, M. S^e remarks, by Reeves, Good, etc., — 131 
girls in 186 ca.ses. This accords entirely with our own experience, and in 
a very interesting statistical report by Dr. George S. Gerhard, based on 
80 cases observed in this city (Anier. Jour. Med. Sciences, July, 1876, p. 
09), the number of female patients just doubles that of the males, 53 to 
-'7. Of the 65 ca.«es occurring in the Children's Ho.'jpital, tabulated above, 
38 were in girls, 27 in boys. 

This excess of females over males obtains in chorea of every grade, 
from the mildest to the most rapidly fatal cases. 

Rrtpid grou'ih and the second dentition probably act, in a considerable 
degree, as predisposing cau.«es of the disea.^e. Particular attention i.s 
drawn to these conditions by MM. Rilliet and Barthez, and the preci.<e age 
at which it is meet frequent (between six and eleven years), would seem to 
show that they exert a very positive influence. The general deterioration 
of the health, resulting in an.'emia, and the oxagpcratod nervous suscepti- 
bility, so often observed at these periods, are probal)ly the immediate causes 
of the frequency of the disease at this epoch of life. 

Drs. Gerhard doc. cit. > and S. Weir Mitchell report that they havo ob- 
served that ch<»rea occurs more frequently and in a more .severe form in 
the spring than at any other sea.«on ; and also that relapses of the di.«ease 
a^ most apt to take place at that time. They think this is probably at- 
tributable to the condition of weakness of the system which exists in the 
spring. 

An altered and anrcmic state of the blood has also been 8uppo.«ed, as by 
Ogle ' and Barnes,' to be the efficient and exciting cause of the affection. 

* Brit, and For. Med.-Chir. Rev., Jan. and April, 18«8, pp. 208, 466. 

* Chorea in Pregnancy, Proc. of Obstet. Soc. of London, vol. x, 1868, p. 147. 



586 CHOREA. 

Killiet and Barthez/ also, when speaking of rheumatism as a cause of 
chorea, say that, " while admitting the existence of rheumatic chorea, it 
must not be forgotten that the disease is frequently of a different nature, 
and that we meet in authors with incontestable examples of chorea con- 
secutive to chronic diseases that have produced a debilitated condition of 
the economy, ... as chlorosis, anaemia, and tuberculosis." 

Constitution does not seem to exert much influence in its production, 
though it is generally thought to be most apt to occur in children of deli- 
cate, excitable, and nervous temperament. The belief in hereditary pre- 
disposition seems to be unfounded save in rare cases. The disease appears 
to commence more frequently in spring and summer than in winter, and 
yet it is scarcely known in tropical climates. 

Rheumatism, however, is unquestionably the condition in connection 
with which chorea occurs more frequently than with any other. The evi- 
dence of all observers of experience is unanimous upon this point. M. 
See (Joe. cit.) asserts, after much examination of this subject, that one-half 
the cases of chorea are dependent upon the rheumatic poison. Thus of 
109 cases of rheumatism admitted into the Hopital des Enfants, he found 
that 61 were complicated with chorea. Trousseau^ also states that in his 
experience rheumatism was undoubtedly the most marked cause of chorea. 
M. Henri Roger^ asserts their connection even more strongly, and states 
that " the coincidence of chorea and rheumatism is so common a fact that 
it ought to be regarded as a pathological law, just as much as the coinci- 
dence of heart disease and rheumatism." 

In England, also, this connection between rheumatism and chorea, both 
of the mild and severe or fatal form, is positively stated by numerous 
authorities. Thus in 104 cases of the list collected by Dr. Hughes,* 
" where special inquiries were made respecting rheumatic and heart affec- 
tions, there were only 15 in which the patients were both free from cardiac 
murmur, and had not suffered from a previous attack of rheumatism." 
Hillier {op. cit, p. 236) " believes there is a very close connection between 
these diseases." West (op^ cit., 4th Am. ed., p. 188) says : " Be the exact 
relation then what it may, it does seem that rheumatism, or the rheumatic 
diathesis, is a very powerful predisposing cause of chorea." Dr. H. M. 
Tuckwell, in a valuable article^ on the pathology of chorea, strongly up- 
holds their frequent connection, and cites 17 cases of his own, in 11 of 
which the previous occurrence of rheumatism was allowed, while it was 
denied only in 6. 

Dr. Chambers found that out of 33 cases of chorea in his books, in 6 the 
affection either began during rheumatic fever, or followed immediately after 
it, or else rheumatic fever succeeded to the chorea. In 80 cases of non-fatal 



1 Op. cit., 2eme ed., t. ii, pp. 565-598. 

2 Clin. Med., 2eme ed., t. ii, pp. 160-198. 

3 Arch. Gen. de Med., 1866, vol. ii, p. 641; and 1867, vol. i, p. 54; and Gaz. 
Med. de Paris, March 7, 1868. 

* Guy's Hospital Rep., 2d series, vol. iv, 1846. 
6 St. Barth. Hosp. Rep., vol. v, 1869, pp. 86-105. 



RHEUMATISM AS A CAUSE. 587 

chorea recorded by Ogle/ it appears that in 8 case^ rlieuraatic fever had 
existed. 

On the other hand, several Grerman authoi-s of liigli authority <h) not 
attach so much importance to the causative influence of rheumatism in 
chorea. Thus Romberg* states that he has not observed their connection 
frequently; and Vogel "^ states that, *' although it must be acknowledged 
that chorea may succeed to acute rheumatism, still the frequency of the 
occurrence has been very much overestimated." 

Steiner* also states that out of 252 cases of chorea the disease ensued 
during the decline of acute articular rheumatism in but 4 cases ; of 3 fatal 
cases, however, reported by him, one was complicated with rheumatic heart 
disease. 

AVe must also allude to the argument of Vogel (op. cit., p. 399), that if 
there were any actual connection between these diseases, then more girls 
than boys ought to suffer from rheumatism ; for it is well known that the 
former are predominantly subject to chorea. "Just the reverse happens 
to be the case in rheumatism, which notoriously attacks more boys than 
girls." We have already quoted extensive statistics, which prove tlie truth 
of the first of Vogel's statements ; but we are by no means convinced tliat 
the latter is correct, and that rheumatism is more frequent in boys than in 
girls. On the contrary, the statistics quoted by Tuckwell (loc. cit., p. 102) 
go to show that the reverse even may be the case. Thus during sixteen 
years there were admitted to the Children's Hospital in London 478 pa- 
tients with rheumatism, 252 of whom were females, and 226 males. 

We are not aware of the existence of any accurate statistics of the 
disease in this country in regard to this point, excepting those of Ger- 
hard {loc. cit.), in whose 30 cases rheumatism was assigned as the cause in 
only 4. 

The great weight of evidence, however, which has been accumulated in 
favor of such a connection, together with the decided results of our own 
observation, api^ears to us to leave no doubt that in a considerable ])ropor- 
tion of cases, chorea is in some way connected with the previous occurrence 
of rheumatism. We shall have occasion to call attention to the obscurity 
which frequently attends the manifestations of rheumatism in young chil- 
dren ; and it is, therefore, highly probable that in not a few cases of 
chorea, where, on inquiry, the parents deny the previous occurrence of 
rheumatism, the truly rheumatic nature of some acute febrile attack, with 
which the child may have suffered mouths before, has been entirely over- 
looked. 

We will postpone, until we come to discuss the nature of this affection, 
the consideration of the manner in which rheumatism disposes to chorea, 
whether by directly causing centric lesions, as of the spinal meninges ; or 
by inducing a state of aniemia, impaired nutrition, and preternatural mo- 

» Brit, and For. Med.-Chir. Rev., April, 1868, p. 490. 
' Di». of Norv. Syst (8yd. Soc.), 1863, vol. ii, p. 67. 
" Op. cit., p. 390. 

« Preg. Vjrachr. xcix (xxv, 8), p. 48, 1868; in Schmidt's Jahrb , Bd. 142, No. 
i 1 ^'-'t n. 26. 



588 CHOREA. 

bility of the nervous system ; or whether the choreic movements are in some 
Avay connected with cardiac disease, which so frequently attends rheuma- 
tism in the young. 

Exciting Causes. — Of many exciting causes that have been mentioned 
by different writers, the one most frequent and most clearly proven, is the 
influence of terror. It was assigned as a cause in 31 out of 56 cases col- 
lected by Duflbsse and Bird, in 34 out of 100 cases collected by Hughes, 
in 25 out of 128 by See, in 9 out of 31 by Peacock, in 9 out of 38 by 
Hillier, and in 7 out of 30 by Gerhard. Besides this are cited imitation, 
blows and falls upon the head, fits of violent anger, contrarieties, pro- 
longed excessive mental effort in young subjects, masturbation, the diffi- 
cult establishment of the menstrual function in girls, or suppression of 
that function, the sudden drying up of ulcers or eruptions, and, in females 
after puberty, pregnanfcy, which indeed is a well-ascertained and most im- 
portant cause. 

In a very interesting case reported by Packard (Amer. Jour. Med. 
Sciences, April, 1870, p. 347), a child of 11 was attacked with very violent 
and persistent chorea following severe irritation of the ulnar side of the 
matrix of the right thumb-nail due to a large splinter of wood. The 
chorea persisted, despite judicious treatment and a residence at the sea- 
shore until the irritated filaments of the ulnar nerve were excised, after 
which speedy and permanent improvement ensued. 

Chorea has also been observed in the course of, or as a sequel to, various 
acute diseases, as pneumonia, the eruptive, typhoid, and intermittent fevers, 
and affections of the gastro-intestinal tube. 

Dr. Weir Mitchell (Amer. Jour. Med. Sciences, Oct. 1874, p. 342) has 
called attention, under the name of " post paralytic chorea," to the dis- 
orderly movements of choreic nature which are frequently seen to follow 
paralysis either in the adult or in children. He has pointed out that it is 
not the ordinary infantile palsy, but rather .the hemiplegia of cerebral 
origin, which is apt to be thus followed by chorea; and that the younger 
the child the more likely are these choreic sequelse to ensue. 

Anatomical Lesions. — It would appear that as yet we are unacquainted 
with any truly characteristic lesion in chorea. In many of the recorded 
autopsies, it is stated that no lesion either of the cerebro-spinal axis or any 
other viscus was present. As, however, most of these autopsies were made 
before the improved methods of microscopic examination of the nervous 
system were introduced, they cannot be regarded as conclusive upon this 
point. In many cases, also, the examination of other viscera has been too 
superficial to have led to the detection of minute but positive and impor- 
tant lesions. Upon the whole, therefore, it may be fairly said, that it is 
chiefly the examinations which have been made during the past few years 
which are of real value, and that there is still need of numerous accurate 
autopsies before we can consider ourselves justified in speaking of the true 
lesions in chorea. 

It is evident that the determination of this question presents great diffi- 
culties, apart from the fact that fatal cases of chorea are comparatively 
rare, and that it requires an amount of skill and patient labor, rarely at 



ANATOMICAL LESIONS. 589 

command, to make the examination with the requisite minuteness. One 
of these dithculties consists in the fact tliat, although chorea may exist as 
a special, iudiviciual atiection, there are numerous other cases of nervous 
disease which are of very varied nature, but which are attended with irreg- 
ular muscular movements truly choreic in character. 

We think it highly probable, therefore, that all cases of so-called chorea 
will never be found to be invariably associated with any one anatomical 
lesion. 

Thus, passing to the actual results of post-mortem examination, we find 
a number of lesions recorded which evidently refer to cases of organic dis- 
ease of the nervous centres, which were merely attended with choreoid 
-ymptoms. 

Among these are enlargement of the odontoid process, effusions into the 
arachnoid, tumors in the substance of the brain, abscess in the cerebellum, 
bony plates upon the spinal meninges, and many other entirely discon- 
nected lesions. 

On the other hand there are cases on record, in which careful examina- 
tion has failed entirely to detect any material lesion, either of the nervous 
centres or of the other viscera, and in which the choreic movements were 
probably of a reflex character. 

Of late years, however, since this question has been subjected to more 
frequent and critical examination, there are certain lesions which have 
een found so frequently after death in fatal cases of true chorea, that they 
:iiust be regarded as possessing some detiuite connection with the disease. 
These lesions consist in certain morbid conditions of the heart, and of the 
nervous centres. 

In regard to the lesions of the heart, M. S4e (loc. cit., p. 390) states, after 
a careful examination of eighty-four autopsies, that " in most of the cases, 
and especially in those most strongly attested, chorea is the result of the 
rheumatic diathesis, and that it reveals itself by plastic inflammations of 
the cardiac membranes, of the pleura, and of the peritoneum, with or with- 
out articular rheumatism." 

Bright, Copland, Todd,' Kirkes,' Nairne,' Begbie,* were also among the 
first to call attention to the frequency of rheumatic endocarditis in connec- 
tion with chorea. In an interesting article on "Maniacal Chorea,''^ Tuck- 
well gives an analysis of the lesions in 34 fatal cases of chorea collected 
by himself. In 25 of these the endocardium was found diseased, the pres- 
ence of warty vegetations on the valves being especially alluded to in 20. 
Of the remaining 9, no mention is made of the heart in o, and it is reported 
as healthy only in 4. The pericardium was found disca-od onlv in -^^ of 
the 34 cases. 

In Ogle's fatal ru- - ^"\ (it., pp. 208 and 507), then- w«rr m i i (mh ot 
17 instances more or 1-- lihrinous depfjsit or granulations uj>on the valves 
or some part of the endocardium. In 2 cases only was the pericardium 

> Lumleian Lectures, 1849. ' Medical Gazette, 18o0. 

> London Jour, of Med., 1851. * Edin. Med. Jour., 1852. 
• Brit, and For. Med.-Cbir. Rev., Oct. 1867. 



590 CHOREA. 

diseased. In the 14 fatal cases collected by Hughes (loc. cit), vegetations 
were found on the valves of the heart in not less than 11. 

The results of careful auscultation, during life, come to support those of 
post-mprtem examination. 

Hillier states (op. cit, p. 236) that, " of 37 cases in my note-books there 
was probably organic disease of the heart in 25, and in 4 others there was 
evidence of functional derangement, whilst in 8 only was there no sign of 
cardiac disturbance." 

Jules Simon writes from a large experience, and says : " I have been 
almost always able to detect well-marked evidence of cardiac affection in 
chorea, in the shape of organic murmurs, hypertrophy of the heart, etc."^ 

In our own experience, evidences of rheumatic heart disease have very 
frequently been present in cases of chorea ; and also in cases which have 
come under our care for organic disease of the heart, there has frequently 
been a history of previous attacks of chorea. 

It is sufficiently evident, therefore, that in a large proportion of cases 
of chorea, some morbid condition of the endocardium is present. The 
particular lesion which has been usually found, consists of fine bead-like 
vegetations, which either fringe the border of the mitral valve, or are 
seated upon the auricular surface of its leaflets. 

These vegetations are in most cases readily detached from the valve, by 
lightly brushing them with the tip of the finger, or with a camel's-hair 
brush ; and it has been supposed by some observers, as Ogle and Barnes, 
that they consisted merely of the fibrin of the blood, deposited in the 
agony of dissolution. We believe, however, both from the previous oc- 
currence of valvular murmurs in cases where such vegetations have been 
found, as well as from a careful study of the anatomical descriptions 
of their appearances, and the occasional presence of the positive results 
of embolism, that these vegetations are produced by a process of endo- 
carditis. 

We will, however, discuss the question of their connection with chorea, 
when we come to speak of the nature of that disease. 

In regard to the condition of the nervous system in fatal cases of chorea, 
there is at times no lesion appreciable, even on microscopic examination, 
while on the other hand there is not uufrequently marked disease, either 
of the nervous tissue or of the meninges. 

Thus, in the 14 fatal cases collected by Hughes, the brai7i was healthy 
in 4, only congested in 3 cases ; there was softening of the brain, with or 
without opacity of the membranes and serous effusion in 6, and in the 
seventh with opacity and congestion of the dura mater. 

In 11 of the 35 fatal cases collected by Tuck well, the brain was found 
softened, and in 9 only is it reported as healthy. In the 16 fatal cases re- 
ported by Ogle, the brain was healthy in 6, much congested in 8, softened 
in but 1, and ansemic in 1 also. 

It appears, therefore, that in a notable proportion of the cases upon 

1 Nouv. Diet, de Med. et de Chir. Prnt., Art. Choree (quoted by TucUwell, St. 
Barth. Hosp. Rep,, loc. cit., p. 101). 



SYMPTOMS. 591 

record, positive organic disease of the brain, and especially in the form 
of softening, has been discovered. In a few instances embolism, or occlu- 
sion of the vessels by fibrinous masses, has been observed, either in the 
carotid artery (Ogle), or in the minute arterial branches leading to 
patches of softened brain-tissue (^Tuckwell). We need, however, a large 
series of careful observations to determine more positively how frequently 
lesions of the brain occur, and especially in what proportion of cases em- 
bolism is present. 

The spinal cord has also been found softened with or without opacity and 
thickening of its membranes, though in a much smaller number of cases, 
probably in part because it has not been so frequently examined in such 
case:? as the brain. 

Of the 16 fatal cases reported by Ogle, it5 tissue was congested in 5 ; 
there was slight softening in 2 ; in 1 the upper dorsal region of the cord 
was completely broken down and almost difiiuent. In 2 cases the cord 
was examined by Mr. J. Lockhart Clarke, who found in one {he. cit., p. 
_'21) that "in the lower part of the dorsal region, at the ninth dorsal 
nerves, the anterior columns were swollen, and formed a convex protu- 
berance of considerable size. In a transverse section of the cord carried 
through this part, and examined under the microscope, it was very evi- 
dent that extensive morbid changes had been going on, the white substance 
had been softened, .... and in two or three places there were circum- 
scribed effusions of blood, surrounded by granular exudations, which had 
probably occurred before the effusions." Similar appearances were dis- 
covered in the lower dorsal region in the other case (he. eit., p. 507). 

In a case already referred to, observed by Tuckwell, of rapidly fatal 
maniacal chorea in a lad of seventeen years of age, in addition to several 
patches of embolic softening of the brain, there was marked softening of 
the spinal cord in the middle dorsal region. 

In 3 fatal cases reported by Steiner {he. cit.), there was increase in the 
connective tissue of the spinal cord ; serous eff'usion in the spinal canal ; 
and congestion or effusinn of blood in the membranes at the exit of the 
ner\*es. 

Finally, in the cases where embolism of the brain was observed by Tuck- 
well, there was also minute embolism of the kidneys. 

In a case of fatal chorea reported by Monckton,' embolism of one 
brachial arter}' occurred, and, after death, large vegetations were found 
on the aortic valves. 

We will have occasion to refer again to these various anatomical ap- 
pearances when speaking of the nature of chorea. 

Symptoms; Course; Duration. — The disease may be general or par- 
tial : in the first case, it affects all the limbs, the face, and some of the 
mu>cles of the trunk ; in the second it implicates only one side, the uf)per 
' xt rem i ties, a single memljer, or a certain group of muscles. It liap- 
peus not rarely that the choreic movements are limited to one side of the 
body : thus in 80 cases of non-fatal chorea reported by Ogle {he. cit.^ p. 

> Brit. Hed Jour., 1866, No. 806. 



592 CHOREA. 

488), the right side alone was affected in 24, whilst the left alone was af- 
fected in 20 ; and in 25 both sides were affected, though in some instances 
one or the other side was more involved than the opposite one. Of the 
30 cases reported by Gerhard {loc. eit.), no less than 15 were strictly uni- 
lateral, the choreic movements being confined to the right side in 10 in- 
stances, and in 5 to the left. In a large majority of the recorded cases 
of unilateral chorea, the right side was the affected one. It occasionally 
happens, as noted by Russell (^Med. Times and Gazette, 1868 and 1869) 
and Gerhard {loc. cit.), that a chorea, which begins as unilateral, may 
subsequently invade the opposite side and become general. Of 7 cases 
that we have seen, in which this point was noted, it was general in 4, and 
confined entirely to the right side in 1, and to the left in 2. We shall de- 
scribe first the prodromes of the disease, then the invasion, and afterwards 
the symptoms as they exist in fully developed cases. 

Prodromie Symptoms. — It is doubtful whether there are, as a general 
rule, any well-marked prodromie symptoms. The only ones that have 
been mentioned with any authority are irritability and peevishness of the 
temper, an unusual degree of impressibility, languor, debility, disturbance 
of the organic functions, exhibited by deranged appetite and an irregular 
state of the bowels, and, after a time, a certain quickness and irregularity 
of the movements, which mark the commencement of the characteristic 
symptoms of the malady. 

Invasion. — The onset of the disease is, as already stated, either sudden 
or gradual, so that there may be several days or more before it reaches 
any considerable degree of severity, or it may, particularly when the case 
has been of a sudden and energetic nature, reach its height in a few hours. 
In most cases, however, it begins with some unusual and singular move- 
ments in one of the upper extremities. The choreic movements are often 
observed first in the fingers, and at the same time, or soon after, in the 
face. Sooner or later they increase in severity, and extend to the other 
arm, to the legs, and to the tongue, and the disease is fully developed. 

Sym])toms of Confirmed General Chorea. — When the disease has become 
fully confirmed, the movements are exceedingly diversified and irregular. 
The limbs are agitated by involuntary contractions of the muscles into 
every attitude possible for them to assume. The fingers are opened and 
shut, brought together or separated, without any regularity. The hands 
are flexed and extended upon the forearms, or pronated and supinated, 
whilst the forearms are flexed or extended upon the arms, and the arms 
moved at the shoulders into every imaginable position. Such are the 
irregularity and rapidity of the motions that it is often with great difficulty 
that the patient can seize anything with the hands, and when once the 
object is attained, he frequently cannot do with it what he wishes. This 
imperfect control over the hands and arms sometimes prevents the patient 
from carrying food and drink to the mouth, excepting with the utmost 
difficulty, and may make it necessary to feed the child. 

The inferior extremities are affected in the same way as the arms. 
Walking is always more or less difficult, and in some severe cases imprac- 
ticable. The patient totters from side to side, or walks rapidly a short 



SYMPTOMS. 593 

distance, and then suddenly stops. Sometimes the progress is accom- 
plished in a zigzag direction, ami at others hy tits and starts as it were, 
whilst in othei^s again the walk is rapid and sudden, almost a run. The 
hild often falls while walking or running, either from meeting a slight 
obstacle, or in consequence of the irregular and imperfect muscular action. 
In some instances standing is impossible, the knees bending suddenly under 
the weight of the body. It was no doubt the peculiar irregular and 
dancing movements of the inferior extremities during the attempts to 
walk and stand, that gave to the disease its original name of St. Vitus's 
iance. 

The convulsive movements of the face and head are not less singular 
than those of the limbs. The face is distorted into all kinds of expres- 
sions, so that it assumes by turns that of the most opposite emotions, — 
sadness, terror, joy, or grief. The mouth is opened and shut, or its corners 
Irawn apart, with the greatest irregularity; the tongue is occasionally 
protruded between the teeth, and sometimes moved rapidly in the mouth, 
so as to cause a clacking sound ; the lower jaw is depressed and elevated, 
or moved in a lateral direction, and with such violence perhaps as to 
injure the tongue or teeth. In consequence of the irregular motions of 
the tongue and mouth, articulation becomes difficult, and the child either 
stutters, or speaks slowly and badly, or can pronounce only monosyllables. 
In a case that occurred to one of ourselves, the movements of the mouth 
and tongue were so violent and uncontrollable that the patient, a boy nine 
years old, lost for three weeks all power of speech. He was at the same 
inae unable to open or shut the mouth at will, or to swallow at the proper 
noment, so that in the act of feeding him, which became necessary from 
;]is entire want of control over the arms, the food was constantly sj)illed 
and spluttered about as though by an 'diot. The act of mastication also 
^as quite impossible, so that he could take nothing but fluids for a number 
f weeks. In another case also that occurred to one of ourselves, in a girl 
between eight and nine years of age, and which moreover was a relapse, 
the patient exhibited the same inability to feed herself, and the same diffi- 
' ulty in regard to mastication, so that she had to be nourished for several 
~ on soft fo<^)d. The speech was likewise greatly affected, it being 
lifficult to understand her muffled, thick, and indistinct utterance. 
Whilst the face and limbs are contorted as above desc-ribed, the head 
•^ ved rapidly from side to side, or backwards and forwards, or under- 
onstant rotation, and, in some instances, as in two that came under 
■jr own notice, all power over the muscles of the back of the neck is lost, 
ind the head falls from side to side, or forwards, as in an infant. In 
-evere cases the choreic movements affect the trunk also, so that the 
!it cannot lie upon a l)ed, but rolls and twist* about the floor with 
violence as to bruise and excoriate the skin. Deglutition is some- 
slightly embarra.ssed, and the child is obliged to swallow with great 
i«,M.iity; in some few ca.«e8 a peculiar loud cry, like that which occurs in 
i bysteria, dependent apparently upon spasm of the ]ar}'nx, has als<j been 

observed. The muscles of the external and internal respiratory : 
I are rarely afflcted. though Romberg narrates three remarkable 



594 CHOREA. 

in which dyspnoea, loud whistling respiration, spasmodic contractions of 
the glottis, or hiccup, were present. Occasionally irregular action and 
palpitation of the heart are observed, and have been attributed to chorea 
of its muscular structure. 

In some cases, also, the sphincters of the bladder or rectum are par- 
tially paralyzed. Retention of urine has been noticed in a few cases; 
and, on the other hand, the late Prof William Pepper mentions having 
known incontinence of urine to alternate with chorea of the external 
muscles. 

The disease is unaccompanied by pain unless it be attended with some 
complication, and what is very singular and remarkable, the constant and 
often very violent muscular contractions do not seem to occasion fatigue. 

There is, however, frequently evidence of a want of muscular power, 
which may merely amount to an unusual susceptibility to fatigue on volun- 
tary exertion ; or complete paralysis may be present, especially in the 
form of hemiplegia, in cases of unilateral chorea. This latter is by far 
the most frequent form of palsy in choreic patients, according to our own 
observation. It occurred in no less than 17 of Gerhard's 80 cases — in 10 
times on the right side, and in 7 upon the left. 

The general symptoms require some attention. The choreic movements 
are almost always increased by emotion, as terror, anger, contrarieties, and 
by the consciousness of being observed. Sleep generally suspends them 
•entirely. In very bad cases they are said to produce insomnia, or to wake 
the child frequently in the night. The intelligence is rarely affected, ex- 
cept in very severe and long-continued attacks ; though some authors 
appear to have met with frequent instances of impairment or perversion 
of the intellectual faculties. It is said that idiocy is apt to occur in cases 
which last for a number of years, but it is probable that in such cases the 
•choreic movements have been associated with some organic lesion of the 
■nerve-centres. The temper is often irritable and capricious. General and 
special sensibility commonly remain natural ; though in some cases, im- 
pairment of general sensibility of the parts most convulsed, even amount- 
ing to anaesthesia, is noticed. In simple, uncomplicated attacks, the pulse, 
as a rule, remains natural : the appetite is preserved ; there is no unusual 
thirst, and the bowels continue regular. 

The urine has at times been observed to be of unusually high specific 
gravity, and to contain an excess of urates and oxalates. These con- 
ditions do not, however, appear to be at all constant or characteristic. 

In a considerable proportion of cases of chorea (see statistics on page 
586), a bruit is heard on ausculting the heart, usually of low pitch, and 
not very great intensity. In some cases this is undoubtedly due to the 
vegetations so frequently found on the valves of the heart in this disease, 
but in others it appears to be rather due to the anaemic state of the blood ; 
and in those cases where palpitation exists, it may be due to the irregular 
contractions of the walls of the heart. It has also been noticed that these 
murmurs in chorea are often transitory, and even intermitting. 

The course of the disease is acute or chronic. In a large majority of 
cases it is acute, the symptoms becoming more and more violent until they 



NATURE OF CHOREA. 695 

reach their height, \Yhen thov remain stationary for a time, and then snb- 
side and disapj>ear under the influence of treatnicjit, or in the natural 
course of the malady. It has been frequently noticed that when an acute 
febrile or inflammatory disease is developed during tlie coui^ of chorea, 
the spasmodic movements are very apt to diminish or entirely cease for 
the time. In fatal cases the symptoms are constantly aggravated ; the 
movements become so violent as to make it necessary to secure the child 
in bed, or in a strait-jacket ; the patients, deprived of sleep, become feeble 
and emaciated; the respiration becomes difficulty intelligence is abolished ; 
the pupils are contracted ; and the child dies. 

The duration is irregular, varying in acute cases between one and three 
months. The average duration is probably about six or nine weeks. In 
very slight attacks it may be much less. The duration of chronic cases 
is from months to years. In fatal cases the duration is sometimes very 
short. In one it was only nine, and in another twenty-seven days. The 
local forms of the disease are often peculiarly intractable, and last many 
years. 

Jiehpses. — Relapses are quite common and are said by Trousseau to be 
shorter than the original attack. We have, however, in a few cases, ob- 
served that the relapse was much worse than the first attack. In one case 
in particular, the relapse was one of the most violent and prolonged attacks 
that we have seen. MM. Rilliet and Barthez state they occurred in six 
out of nineteen cases seen by them. The relapses in these cases occurred 
once, twice, and three times. ^I. See (loc. cit., p. 408) says that it is not 
uncommon, after some weeks of respite, or several months of apparent 
recovery, to see the disease reappear with renewed intensity, and be thus 
repeated twice, thrice, and even seven times in succession. Out of four 
patients, at least one, he states, remains thus under the influence of the 
di.sease. Of 158 cases he counted 37 relapses, of which 17 were arrested 
after the second attack ; 13 suffered a third, and 6 a fourth attack ; and, 
lastly, one had seven distinct seizures, each one of which was separated 
from the following by a well-marked interval. In 46 of Ogle's* cases in 
which this point was noted, previous attacks had occurred in 25 ; in 5 of 
which there had been 2 previous attacks, and in 1 no less than 7. Accord- 
ing to Gerhard, relapses, like the primary attacks, occur most frequently 
in spring. 

Nature of Chokea. — In considering the essential nature of chorea, 
it is evident that there are two point« of importance to be determined, 
Damely, the precise portion of the nervous system involved, and the nature 
of the morbid change in this jiart. 

Before alluding to the views which have been entertained in regard to 
the first of these questions, we would refer to the very great irregularity 
which exists in different cases in the extent and distribution of the choreic 
movements. Thus it frequently hapi)ens that the disease is strictly con- 
fined to one or the other side of the Uniy, or it may be entirely symmetri- 
cal. In other cases the muscles of the head and neck may almost or (juite 
escape, while both legs and one or bf)th arms are affected. Or, on the 
other hand, the choreic movements may first appear and remain most 



596 CHOREA. 

severe in the muscles of the face, mouth, and tongue. It seems probable 
to us, therefore, that there is no one special portion of the motor centres 
which is exclusively the seat of lesion in all cases of chorea. In the great 
majority of cases, however, the symptoms are so far uniform that the mus- 
cles of the face and tongue, as well as those of the extremities, are affected, 
and the only peculiarity is that the irregular movements may be confined 
to one or the other side, a circumstance susceptible of ready explanation. 

Marshall Hall considered chorea as an affection of the true spinal sys- 
tem, and possibly in some cases where the choreic movements are limited 
to the extremities and symmetrical, this supposition may be correct. 

In the vast majority of cases, however, it is undoubtedly necessary to 
locate the seat of disturbance in chorea at a higher point in the cerebro- 
spinal axis, one above the decussation of the anterior pyramids, and prob- 
ably in or near the corpora striata. Among the arguments which lead to 
this view, many of which have been advanced by J. Hughlings Jackson^ 
and Broadbent,^ who strongly uphold it, may be stated the following: 
That the muscles of the face are very frequently affected by the choreic 
movements ; that in the great majority of cases the movements cease during 
sleep ; that the affection is frequently limited to one side of the face and 
body, and that the spasmodic movements not rarely terminate in complete 
hemiplegia. In a footnote {loc. cit., p. 93) Tuckwell says : " It is just to 
Dr. Todd's memory to add, that he long ago (^Lancet, 1843, vol. ii, p. 463) 
showed that the choreic phenomena cannot be explained by the hypothe- 
sis which refers them to irritation of the spinal cord. He says : ' The 
hemiplegic tendency is utterly inexplicable according to that view. The 
affection of one-half the body would alone refer to some point above the 
decussation of the pyramids as the seat of irritation.' " The supposition 
of Carpenter and others that the cerebellum is the seat of the disturbance 
in chorea, was based upon the view that that organ possessed the chief 
power of co-ordinating muscular movements. Recent researches into the 
functions of the cerebellum, as well as the arguments which have been ad- 
duced above, render this supposition untenable. 

The further question now remains as to the condition into which the af- 
fected part of the motor centres is brought, in order to produce the phe- 
nomena of chorea. And it is especially in regard to this point that the 
investigations of Jackson and Broadbent, above referred to, are of so much 
value. These pathologists, and paticularly the latter, have called atten- 
tion to the fact that the choreic phenomena are symptomatic merely of the 
seat of the disease, and that the only essential condition of their production 
is an impairment of vigor and instability of the sensori-motor ganglia, a 
condition which may probably be induced in different ways. 

We are now prepared to consider the manner in which the various causes 
of chorea may be supposed to act. 

We have already seen that in a certain number of cases chorea is inde- 

1 Keynolds's Syst. of Med., Art. Chorea, vol ii, p. 127, footnote ; and Med. Times 
and Gaz , March 6th, 1869. 

2 British Med. Jour., 1869. 



NATURE OF CHOREA. 5lM 

pendent of any appreciable lesion of the nervous system. In some of tliose 
cases it is possible that the impaired nutrition of the motor centre may 
result from an altered and ana^nic state of the blood ; and, indeed, it ap- 
pears to us quite as reasonable to explain a certain class of case* of chorea 
in this manner, as to apply the same explanation to analogous cases of 
paralysis. 

It is probable, also, that in another group of cases, chorea may be reflex 
in character, and depend upon a different degree of that peculiar action 
upon the motor centres which produces reflex paralysis, whether by ex- 
hausting their excitability or by causing a reflex spasm of their vessels. 
This view is maintained by Broadbent {loc. cit.) as well as by Radcliffe,^ 
who states that irregular choreic movements may be produced not only by 
injury of certain parts of the nervous system, but by injury of certain 
nerves at a distance from the nervous centres, the portions of the cerebro- 
-piual axis which are concerned in the development of such movements, 
being afl^ected by reflex action. 

It is probable that if this mode of production be admitted, it will serve 
to explain a large number of cases of chorea, both where the source of irri- 
tation is at a distance (as in cases of pregnancy, or where there are worms 
in the intestinal canal, or, as in the case already quoted from Packard, 
where a splinter was lodged in the matrix under a finger-nail) and where 
it is seated in immediate connection with the nervous centres. As instances 
of the latter kind, may be suggested such conditions as thickening of the 
meninges of the brain or spinal cord, and the presence of bony spicuhc de- 
veloped in the meninges. 

Finally, we must admit as a cause of chorea, primary alterations of the 
tissue of the sensori-motor ganglia and adjacent parts ; the degree of dis- 
ease not being so great as to abolish entirely their function and produce 
paralysis, but only suflicient (as for instance would be secured by an early 
.^tage of softening) to weaken it and render it unstable. 

It will be seen from the foregoing remarks that we deem it impossible, 
at least in the present state of our knowledge upon the subject, to consider 
the cause and mode of production essentially the same in all cases of 
chorea, and that we are disposed to admit the existence of cases due to 
mere anajmia and impaired nutrition, or to an altered stute of the blood ; 
of cases due to reflex irritation, in both of which clavSses of cases, some 
minute and as yet inappreciable lesion may exist ; as well as of cases wliich 
are due to priraar}' material altemtions of the sensori-motor ganglia. 

We have already, in considering the causes and anatomical appearances 
of chorea, had occasion to dwell upon the connection which exist** between 
it and rheumatism, and before leaving the present subject it is desirable to 
refer to the various explanations wliioh have been ofll'red of tiiis circinn- 
stance. Among these, the most important and interesting is that of Kirkes,^ 
who, noticing the frequent presence of vegetations upon the valves of the 
■ » 

> Reynolds's Sjrst. of Med., Art. Chorea, vol. {{, p. 126. 
» Med. Times and Gaz., 18C3, vol. i, pp. 636 and 662. 



598 CHOREA. 

heart in fatal cases of chorea, was led to suggest that very small fragments 
of fibrin might be detached from the valves, and entering the circulation 
cause temporary obstruction of the minute capillaries of the nervous cen- 
tres, producing irritation and impaired nutrition. This theory, which at- 
tributes the production of chorea to embolism, has been accepted by J. 
Hughlings Jackson (Joe. cit.), by Savory,^ by Tuckwell (loc. cit), and, in 
part at least, by Broadbent (loc. cit). 

It is supported strongly by the facts that continued observation of cases 
of chorea has shown even more clearly the very frequent existence of 
cardiac murmurs during life, and of vegetations upon the valves after 
death ; that complete paralysis, usually in the form of hemiplegia, fre- 
quently follows the choreic movements ; that in many fatal cases there is 
found just such cerebral softening as follows embolism ; and, finally, that 
in a few cases, already referred to, the existence of embolism has been 
actually demonstrated. 

It is also to be borne in mind that recent researches have shown that 
endocarditis with the production of fine vegetations on the margins of the 
cardiac valves, is not a complication of rheumatism alone, but occurs in 
connection with scarlatina, diphtheria, and some other acute specific dis- 
eases. If then the theory is finally substantiated which would explain some 
cases of chorea as the result of minute embolisms, it is possible that it may 
be found that such is the mode of production of a part of the post-scar- 
latinal or post-diphtheritic choreas. 

There have, however, been numerous objections advanced against this 
theory, the most powerful of which are urged by Barnes (loc. cit) and 
Ogle {loc. cit.). Thus it has been objected that, on the supposition of nu- 
merous minute fragments of fibrin circulating in the blood and becoming 
impacted in the minute capillaries, it w^ould be difficult to explain the fact 
that chorea is so frequently unilateral, or even localized in a single group 
of muscles. It must be remembered, however, in answer to this, not only 
that in some cases of fatal chorea embolism of single large arterial 
branches has been found, but that the number of minute fragments of 
fibrin detached from the heart's valves may be very small, and that it 
is quite supposable that they should in some instances nearly all pass 
into the iunom.inate, or the left carotid artery, and thus be chiefly dis- 
tributed to one side of the brain. It may be mentioned also in this con- 
nection, that it is especially in these cases of unilateral chorea that the 
affection is succeeded by pamlysis, such as might readily follow in case of 
embolism. 

Again, it has been objected that if chorea be invariably dependent upon 
embolism, the results of this accident must be of a very transient and 
trifling character, since in so great a majority of cases the disease termi- 
nates in complete and permanent recovery. The weight of this objection 
must be admitted, and yet Tuckwell fairly remarks in answer to it, that 
the "mere fact of recovery is not enough to condemn the notion of embol- 

1 St. Barth. Hosp. Rep., vol. i, 1865, p. 107. 



DIAGNOSIS — PROGNOSIS. 599 

ism. Ou the other hand, the very frequent presence of a cardiac niiir- 
nuir, even in the milder attacks of chorea which recover, would rather 
dispose me to look for the same exciting cause in the mild as in the severe 
cases, viz., embolism." It is evident also that if the supposed embolus 
were minute, and therefore obstructed only a very small vessel, a collateral 
circulation might soon be established and restore the nutrition of the area 
aflected. 

Another objection advanced by Ogle [he. cit., p. 232) is, that in other 
cases of capillary embolism the symptoms produced are not those of 
chorea, but rather of pyi\?mia or of gangrene. It is quite evi«lent, how- 
ever, that these symptoms alluded to (which are met with for instance in 
ulcerative endocarditis) are due, as remarked by Savory and Tuckwell, 
not to the mere capillary embolism, but to the concomitant septic condi- 
tion of the blood. In this connection, reference may be made to the 
elaborate experiments of Panum as to the results of embolism ^Arrh. f. 
Path. Anat., xxv, 308, 433; Syd. Soc. Year-Book, 1863, p. 211), in which 
he demonstrates that embolism of the vessels of the brain and medulla 
oblongata is followed by tetanic symptoms. 

This extremely interesting question cannot be considered as definitely 
settled ; there is still needed a series of careful examinations in regard to 
the various points under discussion. It appears to us, however, conclu- 
sively shown that, in a certain number of cases, the peculiar irritation and 
impaired nutrition of the sensori-motor ganglia, which leads to the devel- 
opment of the choreic phenomena, are due to embolism of the vessels 
supplying these parts. We have, however, already expressed our opinion 
that, at present at least, there must be admitted two other classes of cases 
of chorea, due primarily to alterations in the blood and to reflex irrita- 
tion respectively. It is quite possible, therefore, that in some instances 
rheumatism induces chorea indirectly, either by causing amemia and im- 
paired nervous vigor, or by causing inflammatory lesions, as of the spinal 
meninges or sheaths of spinal nerves, which may serve as the foci of reflex 
irritation. 

Diagnosis. — The diagnosis of chorea cannot be attended with any diffi- 
culty, and we shall therefore make no remarks upon it. 

Pk<k;noji.s. — Idiopathic simple chorea in young children is rarely a 
fatal disease. Nevertheless, even under these circumstances, it sometimes 
terminates fatally, and usually from exhaustion. Thus MM. Rufz, Legcn- 
dre, and Rilliet and Barthez have each met with an instance. M. See {loc. 
eit., p. 406) states that of 158 cases, 4 passed into the chronic condition, and 
9 proved fatal. Dr. Copland states that he ha.<< met with 3 or 4 fatal ca-ses, 
that Dr. Prichard has recorded 4, and that Di*. Brown refers to 3 in his 
practice; but he does not inform us whether they were idiopathic, rompli- 
cated, or symptomatic. We have already referred to the list of 14 fatal 
cases, of which the autopsies were reported by Dr. Hughes {loc. cU.)\ and 
to the 34 additional fatal cases collected by Tuckwell (loc. cit.). Dr. J. W. 
Ogle has lately (Brit, and For. Med.-Chir. Rev., January and April, 1868) 
published the details of 19 more fatal cases ; and from the same source we 



600 



CHOREA. 



quote the following table as exhibiting the mortality from this disease in 
Great Britain during 23 years. 









Deaths from Chorea. 








Deaths from Chorea 


1839, 54 


1855, 69 


1840, 










25 


1856, 








. 59 


1841, 










28 


1857, 








. 44 


1842, 










19 


1858, 








. 53 


1847, 










39 


1859, 








. 55 


1848, 










38 


1860, 








. 66 


1849, 










34 


1861, 








. 71 


1850, 










60 


1862, 








. 52 


1851, 










77 


1863, 








. 63 


1852, 










73 


1864, 








. 73 


1853, 










67 


1865, 








. 88 


1854, 










48 


Total during 23 


years, 1255. 



It is quite possible, however, that many cases of organic disease of the 
nervous system merely attended with irregular choreoid muscular move- 
ments have been included in these reports. On the other hand, out of 
84,332 deaths at all ages occurring in this city during seven consecutive 
years, but 3 are attributed to chorea. It must not, however, we think, be 
positively inferred from this that severe and fatal chorea has been really 
so rare among us ; since, during the same time, there are reported in addi- 
tion to the deaths from convulsions, 79 deaths from cramps, a vague and 
most improper term, which, in all probability, includes a certain propor- 
tion of cases of chorea. 

In regard to any special rules in prognosis. to be deduced from a study 
of the fatal cases, it may be observed that their average age is consider- 
ably greater than that of ordinary mild chorea. Thus in 17 out of Ogle*s 
19 fatal cases, but two were under the age of ten ; the average being 
15-|ths years. 

So too in 32 of Tuckwell's 34 fatal cases, 21 were at or above the age 
of fourteen, and 6 of this 21 were at or above the age of twenty. 

The duration of the case scarcely seems to have a direct bearing upon 
its fatality. It is true that in cases which have passed into the chronic 
form and persisted for several months, the prospect of being able to effect 
an entire cure diminishes, but still such patients may live very many years, 
and ultimately die only from some intercurrent disease. And, on the other 
hand, death has been known to occur as early as the end of the first week. 
Of course the existence of any serious complication, and perhaps especi- 
ally of marked cardiac disease from previous rheumatic attacks, renders 
the prognosis unfavorable.' 

Of 58 cases treated in the Children's Hospital of this city, the average 
duration of treatment was 39 days. Of this number, 42 were discharged 
cured, 13 much improved or almost well, and 3 without any improvement. 

In conclusion, whenever, in a case of chorea, the convulsive movements 
become incessant, and the respiration embarrassed, and still more when 
subsultus tendinum takes the place of the choreic movements, a fatal ter- 
mination is greatly to be apprehended. 



TREATMENT. GOl 

Treatment. — Many different plans of treatment, and a groat variety 
of drngs have been proposed for the cure of the disease under consider- 
ation. These facts alone may serve to teach us that the effects of treat- 
ment are not clearly appreciated, and also, when taken in connection with 
the circumstance that fatal cases are rare, that the disease tends naturally 
to recovery in a good proportion of the cases. This feature of the natural 
history of the disease is shown also by the evidence rrlvon by Dr. Bardsley, 
who mentions, that in the Manchester luffrmary, notwithstanding the va- 
riety of treatment adopted by successive practitioners, an incurable case 
had not presented itself in the course of thirty-three years. (Tweedie^s 
Lib. Pnict. Mtd., Am. ed., vol. ii, p. 46.) 

The only rules to be laid down for its treatment are those which apply 
to all the convulsive afl^ections depending on functional disorder of the 
nervous system, and on disordered states of the general health, connected 
with a faulty condition of the functions of digestion and assimilation. 
These are attention to the general health, and especially a careful regula- 
tion of the diet and other hygienic conditions of the patient, the removal 
of any local derangement or disease that may exert an unhealthy influence 
upon the nervous system, the use of tonics and iron, and the employment 
of such remedies as have been found to exert a controlling effect upon 
spasmodic and convulsive affections generally, and upon this disease in 
particular. 

We shall consider, under different heads, the various means that have 
been recommended, endeavoring in the course of our remarks to distinguish 
the cases to which each remedy is best adapted. 

Purgatives. — This class of remedies has been extensively employed and 
often exclusively relied upon by some very high authorities, especially the 
English. When relied upon exclusively in the treatment, an active ca- 
thartic is given every day, or every second or third day ; and there can be 
no doubt that many cases have recovered under this plan. In our own 
practice we must say that the treatment by cathartics alone has never suc- 
cee<1e<l well, and we have only used them of late to such an extent as was 
necessary to secure a soluble and healthful condition of the bowels. When, 
therefore, the stools are natural and healthful in all respects, we do not 
think it prof)er to employ jwwerful purgatives in the treatment of the dis- 
ease. We resort to them only when there is constipation, or when the 
discharges present some unnatural appearances as to color, odor, etc. 
Under the latter circumstances we may resort to any of the somewhat 
active cathartics, as cream of tartar and jalap, sulphate of magnesia, rhu- 
barb, alfH?s, etc. When the discharges from the bowels are clay-coIorcd, 
or dark and offensive, when the mouth is pasty, the tongue loaded with a 
thick yellowwh fur, and the breath h^avy, it is proper to employ a mercu- 
rial. Dr. Copland advises that we should commence with the exhibition 
of a full dose of calomel, either alone or with other purgatives, or followed 
by them in five or six hours. He adds that the doses of calomel ought 
not to be frequently repeated in the disease, and thinks that it is not ser- 
viceable " to continue purgatives long, without either exhibiting them with 



602 CHOREA. 

a bitter tonic or antispasmodic remedy, or with both, or alternating them 
with those remedies." 

Antispasmodics are amongst the most important remedies we have to 
oppose to the disease. The weight of evidence seems to show, indeed, that 
they, in conjunction with a moderate use of purgatives, of tonics, especi- 
ally ferruginous tonics, and of certain particular remedies, and with care- 
ful regulation of the hygienic conditions of the patient, ought to constitute 
the treatment in the great majority of cases. Of the various remedies of 
this class that have been employed, those which have exerted the most 
beneficial influence are valerian, assafoetida, oxide of zinc, camphor, *the 
root of the cimicifuga or black snakeroot, and the bromide of potassium. 

Particular Remedies. — Of the remedies belonging to this class, we shall 
first mention cimicifuga, which has always been much employed in this 
city. This was first introduced into use by Dr. Jesse Young, and is now 
extensively employed and much relied upon. Dr. Wood {Pract. of Med., 
vol. ii, p. 755), says : " I have in repeated instances found it of itself ade- 
quate to the cure of the disease." We have employed it ourselves quite 
frequently in primary cases, and in two cases of relapse. In several of the 
former the children recovered entirely under its use ; in some, however, 
it failed to do any good, and recovery took place under the use of iron, 
arsenic, the sea-bath, and in the course of time. In the two relapsed cases, 
the patients recovered finally under the use of the cimicifuga, iron, cod- 
liver oil, and good diet. One of the cases that recovered under its use 
was among the worst we have ever met with. It was that of a boy of nine 
years, in whom the disease went so far as to destroy all power of locomo- 
tion. The child was unable even to stand. At the same time, the move- 
ments of the lips, cheeks, and tongue were so violent and irregular, and 
so little under the control of the will, that the power of speech was lost en- 
tirely for a period of four or five weeks. The choreic spasm appeared to 
afl^ect even the muscles of deglutition, so that the act of swallowing was 
often difficult and uncertain. Mastication also was impossible, and the 
child was unable to carry anything to its mouth, rendering it necessary to 
feed him, as one would a baby, with soft solids and fluids. During some 
two months, the muscles at the back of the neck were so weakened that 
the head could not be lifted from the pillow or held direct, but fell from 
side to side or forwards like that of an infant. The condition of the child 
was altogether one of the most complete and distressing helplessness. 
During the first month of the case, it was treated with active cathartics, 
chiefly very large doses of cream of tartar and jalap, and with iron, but 
as the symptoms became worse and worse, the cathartics were abandoned 
except so far as to maintain by the occasional use of rhubarb and senna, 
a soluble state of the bowels, which were very much disposed to constipa- 
tion. The patient was now put upon the use of decoction of cimicifuga, 
of which he began with four ounces, soon increased to half a pint per day, 
made in the proportion of half an ounce to the pint. The iron was con- 
tinued. Under this treatment he very soon began to amend, and in two 
weeks showed a very decided improvement. Cod-liver oil was now added 
to the iron and cimicifuga, and in six weeks he was in great measure re- 



TREATMENT. 603 

stored to health, and in the end recovered completely. In another case 
almost a^ bad as this, the patient finally recovered under the same treat- 
ment. 

The cimicifuga is given in powder, tincture, decoction, or Huid extract, 
and should l>e continued for several weeks in gradually increasing doses, 
until some visible effect is produced, a,s nausea, headache, vertigo, or dis- 
ordered vision. The usual doses are from half a drachm to a drachm of 
the powder, from one to two ounces of the officinal decoction, and one or 
two drachms of a saturated tincture, given three times a day. For our 
own part we prefer the decoction, of which we give to children of eight or 
nine years old, from four ounces to half a pint a day, made in the propor- 
tion of half an ounce of the root to a pint of boiling water. Prepared in 
this way, it is not a disagreeable drink, and is usually taken without much 
objection. 

The bromide of potassium in full doses has in some cases in our expe- 
rience proved of marked benefit. "NVe have used it especially in those 
cases which were connected with rheumatism as a cause, and have then 
frequently administered it in combination with the iodide of potassium 
and the iodide of iron. 

Some French authors recommend chiefly valerian, oxide of zinc, and 
assafcetida. Of these the one which has the highest reputation is valerian, 
and from the evidence adduced in its favor there can be no doubt tliat it 
exerts a very beneficial effect upon the disease. It may be given in the 
form of powder, infusion, or fluid extract. The dose of the powder is from 
twelve to eighteen grains in the day, to commence with, to be rapidly in- 
creased to several drachms, as the stomach becomes accustomed to it. It 
may be given in honey or preserve-syrup. We should prefer the fluid 
extract, of which half a teaspoonful may be given to a child eight or ten 
years old, three times a day, and the quantity gradually increased. The 
oil of valerian is employed by some practitioners. Oxide of zinc is given 
in doses of a grain every three hours to children eight years old, and is 
much relied upon by some practitioners. Assaf«T?tida is recommended both 
by English and French writers. It is best given in pill, on account of the 
nauseous taste of the mixture. Two three-grain pills may be given to a 
child of four or six years of age, three times a day. Dr. Bardsley gave 
it by injection, in combination with laudanum, every evening, after using 
musk and camphor, through the day. 

Xarcotic^ have been recommended by .«»ome writers. Those whirh are 
most employed are opium, belladonna, stramonium, and cannabis Indica. 
Substances of this cla.«a are seldom, however, made the basis of treatment. 
Opium is useful in some cases in which the agitation is very great, so that 
the sleep of the child is much disturbed, but it is seldom necessary except 
as an adjuvant to other nif an- : an<l tho remark applies equally to other 
remedies of the clas.-. 

Arsenic. — There is no nin<<iy m rr;_'ard to uh .-< < urative action in 
chorea testimony is more unanimous. Bomber^ .inl iJ-gbie sjx^ak of it 
as curing the affection in as short a timo and with even greater r-frtainty 
than any other remedy ; and Trousseau also testifies to its good offjct,", but 



60-1: CHOREA. 

adds that it has the disadvantage of being difScult of administration, 
owing to its irritant properties. Gerhard {loc. cit.) also speaks of it as 
having proved of marked benefit in his hands. Dr. Radcliffe, who has 
met with the same difficulty in maintaining the use of full doses of this 
remedy for any length of time, has tried with apparently marked success 
the hypodermic injection of Fowler's solution. He was first led to employ 
this in cases of chronic local chorea in adults, where the injection of doses 
of Fowler's solution, yarying from five to fourteen minims, produced a 
speedy cure. He has also employed it successfully in two cases of general 
chorea, the duration being twenty-eight and thirty-two days respectively. 

The usual manner in which we have administered it is in the form of 
Fowler's solution, given in the ordinary doses, and immediately after eat- 
ing, and steadily persisted in until some evidence of its constitutional 
effects are produced. By carefully watching for these, and immediately 
reducing the dose until the signs of irritation have passed away, and then 
again cautiously increasing it, we have usually been able to administer it 
without serious inconvenience, and with excellent results in a large propor- 
tion of cases. This preparation may also be advantageously combined with 
the bitter wine of iron. 

Strychnia. — Trousseau recommends more highly than any other plan of 
treatment, the use of sulphate of strychnia in gradually increasing doses, 
until the extreme limit of tolerance is reached. He begins by giving gr. 
^Vth twice or thrice daily, to children between five and ten years old, and 
cautiously increases this dose until it reaches about gr. |th in twenty-four 
hours. The results obtained by this treatment in Trousseau's hands cer- 
tainly appear good, but the risk attending it and the care demanded to 
prevent accidents are so great, that we should prefer some of the equally 
successful and less dangerous methods. It appears, however, that other 
observers, as West, have obtained good results from its use in doses much 
smaller than those recommended by Trousseau, not exceeding gr. ^'jth 
thrice daily, for children of eight or ten years of age. 

Conium maculatum, given in the form of the succus conii, has been highly 
recommended by Dr. John Harley (The Old Vegetable Neurotics, London, 
1869), in the treatment of chorea ; and a certain number of cases have 
already been reported of its successful administration. Dr. Harley pre- 
scribes the succus in the doses of 20 or 30 drops for a child of six months 
old ; a drachm for one over two years old; and from one to two drachms 
at ten years of age. In explaining the use of doses so large as these, he 
insists upon the fact " that hemlock given in doses which fall far short of 
producing its proper physiological action, is useless for the treatment of 
the diseases to which it is adapted." We have not had any extended ex- 
perience ourselves with this drug in chorea, but from our observation of 
its use in other conditions we should strongly advise beginning with much 
smaller doses, and gradually increasing as they are found to be tolerated. 

Bouchut gives (Bull, de Ther., April 15th, 1875, quoted in Medical 
Times and Gazette, June 5th, 1875) the results of numerous trials of eserin, 
the active principle of calabar bean, in chorea. It may be given either 
hypodermically or by the stomach : in the former way it is most energetic, 



TREATMENT. 605 

and must be given in doses of rj\,th to y'-th of a grain (3 to 5 milligramnios) 
three times a day ; by the s^tomach, one-half as mueh more may be given. 
Its action is temporary, histing two or three houi-s. It often causes, in the 
above doses, some uneasiness and restlessness, and occasionally nausea. It 
arrests the choreic movements during its action, and gradually eflects a 
permanent moditication in them, so that, according to Bouchut, the cure is 
effected in ten days on an average. 

Stimuli. — The well-known views of Dr. Kadcliffe upon the pathology of 
spa:«modic affections, have led him to recommend the free use of alcoholic 
drinks, to the point of obtaining their decidedly sedative action on the 
economy, as the foundation of a rational treatment in chorea. 

Without being prepared to adopt this as a regular plan of treatment for 
ordinary cases of the disease, we should certainly be dis})osed to admin- 
ister alcoholic stimuli whenever the symptoms indicated the approach of 
nervous exhaustion. 

Tonics. — Whenever the disease occurs in debilitated and auicmic indi- 
viduals, remedies of this class are evidently necessary, and prove of great 
efficacy. The ferruginous preparations are "those most clearly indicated 
under the circumstances ; and, indeed, there are many authorities, a» Wat- 
son, Elliotson, and others, who consider the preparations of iron sufficient, 
of themselves, to cure almost all cases of chorea. Any of them may be 
selected. The best are the subcarbonate, Vallet's pills, the syrup of the 
iodide, and the pure metallic iron (ferrum per hydrogen). Quinine is also 
recommended when the patient is feeble and weak. It may be given 
alone or in combination with iron. The citrate of iron and quinine would 
form a very good prescription under the circumstances mentioned. Cod- 
liver oil is an admirable remedy when the child is thin and weak, and 
especially when there is cause to suspect any tubercular predisposition. 

A great variety of remedies besides those we have mentioned have been 
employed, and have more or less evidence in their favor. Amongst them 
are sulphate and iodide of zinc, nitrate of silver, subnitrate of bismuth, 
iodine, calabar bean, and a host of others which it is useless to enumerate. 
The sulphate of zinc has undoubtedly proved efficacious in some instances. 
About two grains may be given at first three time* a day, and gradually 
increased to six or eight if the stomach bears the remedy well. 

External Remedies. — The cold plunge and shower bath as well as cold 
affusions to the nape of the neck and along the spine have been frequently 
employed as adjuncts to the internal treatment, and are of unquestionable 
value in many instances. The cases in which they are used should, how- 
ever, be selecteiJ. They ought not to be employed unless followed by full 
reaction, nor unless the child is willing to take thera. When the use of 
the bath terrifies or shocks the patient greatly, it cannot be proper. A 
warm or tepid l>ath u.«ed once a day, or every second day, would always 
be useful in promoting the general health, when the cold bath is not 
bonie well. Ether spray has been recommended by Lubelski ( (Jnz. Jlrhd.^ 
April 19th, 1867), as an application along the spine, and a number of 
cases in which iti* use was successful have V>een placed on record. 

Sulphurous baths have been recommended and employed with much 



606 CHOREA. 

success, by M. Baudelocque of Paris. A rapid and definite cure was 
obtaiued in 68 out of 65 cases. Thirty drachms of sulphuret of potas- 
sium are added to each bath, which is employed for at least one hour 
daily, at a temperature of 91°. Generally amelioration occurs after the 
second or third bath, but sometimes not until after twelve or fifteen days, 
a mean of twenty-two days having served for the cure of fifty out of fifty- 
seven cases. Where the cure is retarded, it ordinarily depends upon the 
patient's powers being lowered by other remedies or insuflScient diet, upon 
irritation of the skin induced by the bath, or upon acute irritation of the 
internal serous membranes, — circumstances contraindicating the baths 
while they continue. The conjunction of other remedies retards rather 
than aids the cure. Deducting the cases in which the bath was improp- 
erly used under the above circumstances, there remain but nine true 
failures in eighty-one cases, these being almost all recent or rheumatic 
choreas. (S6e on Chorea, Banking's Abstract, No. 16, p. 51.) 

Counter-irritation to the spine, in all its shapes, from pustiilation with 
tartar emetic, issues, and blisters, down to frictions with coarse towels, has 
been proposed and employed in the treatment. The use of any but the 
milder remedies of this class is unnecessarily harsh and cruel, except when 
the disease is evidently dependent upon an afiection of the brain or spinal 
marrow. The great majority of cases will recover perfectly well without a 
resort to such violent means, and they ought therefore to be avoided. 

Electricity has been resorted to, and apparently with good effects in 
some instances, and it might therefore be tried when other and simpler 
means fail, or in conjunction with these means. In cases where the spas- 
modic movements are constant and persistent despite the use of internal 
remedies, the inhalation of anaesthetics has been tried, but with uncertain 
results. 

In violent cases, it is of course desirable to confine the patient to bed ; 
and it may be necessary to have padded sides made for it to prevent him 
from dashing himself out of bed in his uncontrollable and violent move- 
ments. In such cases it may even become necessary to employ padded 
splints, or to envelop the body with bandages carefully applied over 
layers of wadding, so as to secure the legs together, and to confine the 
arms by the sides. 

Gymnastic Exercises. — M. See (loc. cit.,- p. 481) says that this method is 
one of the best that has been employed. He states that it was recom- 
mended by Darwin, and then by Mason Good, and was first employed by 
Louvet Lamarre in one case, after which it fell into oblivion until some 
of the physicians of the Children's Hospital, at Paris, and amongst others, 
MM. Bouneau, Baudelocque, Guersant, and Blache, " struck, no doubt, 
like myself, with the good effects of gymnastics in scrofula and other ca- 
chectic diseases, and taught especially by the effects of musculation on the 
general health, conceived the idea of applying this treatment to nervous 
diseases, and particularly to chorea, which, besides the perturbation of the 
nervous system, is so often attended with disorders of nutrition and of the 
functions of organic life. To put a stop to this state of languor, to re- 
establish at the same time the equilibrium of the movements, which are 



TREATMENT. 607 

rather irregular than convulsive, to endeavor, in fine, by regulating the 
contractions, to break up their vitiated habit, — this is the triple object 
sought to be attained by gymnastics. Be it theory or empiricism, success 
crowned these previsions, and proved the utility of the new treatment, of 
which we are about to study the methods and it:s consequences." M. See 
says, that to commence the treatment, we must prescribe first simple and 
cadenced movements, and exercise at the same time the larynx by means 
of singing. " To place the child in a vertical position, make it fiex and 
extend the knee^, touch the ground, stretch out and bend tlie arms, har- 
moniziuu at the same time these various movements bv rcixulated sin<;ing:, 
— such are the first means by which to replace the contractions under the 
power of the will. This end will be so much the more rapidly attained, 
as the attention of the patient is the less distracted, its intelligence tlie 
less changed, and its temper the less capricious ; so also is it often impos- 
sible to succeed unless we first obtain control over the patient by kindness 
and gentleness. 

"After reaching this point, we may attempt walking, regulated to a 
slow or quick step, running, jumping, hanging by the arms, or other more 
complicated movements, always graduating them to the degree of the dis- 
ease, watching them most carefully, and repeating them daily without pro- 
longing them beyond fifteen or twenty-five minutes, in order to avoid mus- 
cular fatigue and palpitation of the heart, which occur sometimes when the 
exercises are too long continued. 

*' With these precautions, and no matter how severe the symptoms, we 
may, after a few lessons, and sometimes after the first, and at latest after 
the fifth or sixth, perceive a manifest change in the abnormal mobility, 
which is usually so rapid that we are generally able to decide, after the 
first eight days, as to the eflicacy of the treatment. When, after this 
length of time, the patient can neither stand erect, walk in a straight line, 
nor hang by the arms, there is reason to fear that the method will fail ; it 
is at least certain that it will be tedious and difficult." 

In Hanking s Abstract (loc. cit.y p. 50; may be found the following 
statements in regard to the treatment by gymnastic exercises : 

They were first employed under the guidance of M. Laisn^*, gymnastic 
profes.>Mjr of the Polytechnic .School, their eff'ects being tried first on scrof- 
ulous children. " Commencing with simple movements of the legs and 
arms, accompanied by appropriate wjngs, the children's progress was so 
r;i;id that they were soon able to employ the orthojx'dic ladder, the 
jarallel bars, and other machinery, in succession. By the twentieth les- 
stjii they were exercised in wrestling, and afterwards in running, special 
exercises being devised for the lame. From the first lesson the children 
became fired with emulation, and movements which seeniecl imjK>sj«ible 
were so«jn executed with eaM- and pleasure. A marked ameli(»raMon was 
speedily o^>served, their countenances becoming animated, their fle.-h firm, 
their voices stronger, their appetite keener and more regular; glandular 
swellings, which had long resisted all treatment, were ra^olved, and fi.ntu- 
lous sores, that had been open for vf^n*, closed up. The le?«.*ons, one hour 
each, were given three times a week ; and in the intervals the children 



608 CHOREA. 

amused themselves by repeating such of them as did not require ma- 
chinery." This treatment, at first applied to scrofulous children, was, as 
stated above, extended to those laboring under nervous affections, partial 
paralysis, rickets, and especially chorea. Since 1847, ninety-five children 
suffering from chorea, sometimes so obstinate as to have resisted the most 
various treatment, have been cured by this means alone, or in conjunc- 
tion with others, and no accident has resulted from the employment of 
the exercises. The movements are graduated according to the severity of 
the case, and they are repeated daily, but not for more than from fifteen 
to twenty-five minutes, so as not to induce fatigue or palpitation. " Im- 
provement is sometimes seen after the first lesson, and at latest after the 
fifth or sixth ; so that at the end of a week we can judge whether the 
means are likely to prove efiicacious, and if manifest improvement has 
not then taken place, it is doubtful whether the cure will be thus efiected, 
or if it is, it will be so only after a long time. The worst as well as the 
slightest cases have reaped equal benefit, the cure in the favorable ones 
only requiring a mean of twenty-nine days, and old or relapsed chorea 
being more amenable than recent. Dr. See has found that when other 
remedies are conjoined with the gymnastics, the proportion of cures is 
less, and the period of their attainment later; and he recommends no 
other adjunct to be employed than good diet." (Dr. See on Chorea, loc. 
cit, No. 16, p. 50.) 

Hygienic Tkeatment. — The management of the hygiene of the patient 
is quite as important as any other part of the treatment. The diet should 
be arranged to suit the particular condition of the individual, and with a 
view to procure and maintain the most healthful possible state of the di- 
gestive apparatus. It should always be light and easily digestible, in order 
that neither the stomach nor bowels may be oppressed and deranged by 
the products of an imperfect digestion. When the stomach is weak and 
dyspeptic, the food ought to consist for some days chiefly of preparations 
of milk and bread, whilst in the meantime, a tonic remedy is administered 
internally, in order to invigorate the power of that organ. As the diges- 
tive function becomes stronger, the child ought, as a general rule, to be 
put upon the kind of diet most likely to promote the general health and 
vigor of body. It ought to consist of bread, milk, plain wholesome meats, 
and simple vegetables. Coffee and tea, and all other nervous stimulants, 
had better be avoided. The meats ought to be mutton, beef, or poultry. 
There are few vegetables, besides rice, potatoes, and tomatoes, which are 
suitable under the circumstances. All candies, preserves, unripe, coarse, 
or dried fruit, hot bread and cakes, except the very simplest, ought to be 
withheld. 

Of dress we need merely say that it must be suited to the season. Ex- 
ercise, or at least, exposure to fresh air and insolation, are of the utmost 
consequence. When the disease is so violent as to prevent the child from 
walking, it ought to be taken to drive as often as possible. In cases which 
seem connected with a debilitated and anaemic condition of the constitu- 
tion, removal to the country, and particularly to the seaside, will often 
effect a cure w-ith great rapidity. Whenever, indeed, a patient inhabiting 



ATROPHIC INFANTILE PARALYSIS. G09 

a large city or towu can be conveinently taken to the seaside in the sum- 
mer, it ought to be done, for the change is useful not only at the time, but 
it les;seus, also, by strengthening and invigorating the constitution for the 
future, the danger of a relapse. 



ARTICLE XI. 



ATROPHIC INFANTILE PARALYSIS. 

Paralysis occurs in the young child in almost, if not quite, all the forms 
observed in the adult. Many of these are however rare in childhood : 
whilst, on the other hand, there is one form which, although it is occa- 
sionally observed in the adult, occurs with such peculiar frequency in 
young children as to have received the name of infantile palsy. It is char- 
acterized by total or partial loss of power over one or several groups of 
muscles, usually without impairment of sensation, occurring suddenly as a 
rule, and often followed by atrophy of the pal:?ied muscles, and consequent 
deformities. 

History and Synonyms. — Occasional allusions to infantile paralysis 
may be met with in medical writings even as far back as the latter part of 
the last century, but of such a vague and indefinite nature that the full 
recognition and accurate description of this peculiar affection cannot be 
-aid to date further back than the writings of Kennedy and Heine, in 
183() and 1840 respectively. Since the publication of Heine's classical 
memoir, however, a number of observers have studied the disease with 
much attention and success. We have subjoined a list of the principal 
writings upon this subject to which we have been able to obtain access.* 

* Bibliography. — Underwood, Treatise on Disensesof Children, London, 1789. 

Roj'tan, Rcch. sur le Kamoll. du Cerveau, 2eme ed., Paris, 1823, obs. L. 

Shaw, on Nature and Treatment of Distortions, London, 1823. 

Cazauvit'ilh, Arch. Gen. de M6d., t. xiv, 1827, pp. 6 and 347; Koch, sur I'Agen- 
i^ie et la Paral. Congenitalc. 

Badham, London Medical and Surgical Journal, 1835. 

Kennedy, Observations on Apoplexy and Paralysis of New-born Infants; Dublin 
.Jour. Med. .Scien., 1836; and Dublin 3Ied. Press, 1841 ; and Dublin Quart. Jour. 
■f Med., 1850, and Nov. 1861. 

Marshall Hall. Lect. on Nervous System, London, 1836, p. 81. 

Heine, Beobach. 0. Lahmung^zu.'tiinde der untorn Extrr-mitaten und deren Be- 
handlung, Stuttgart, 1810; and Spinale Kinder Luhmung, Stuttgart, 1860, seo Can- 
stall * Jahr., vol. iii, p. 70, 18<»0; and Med". Times and G««., London, 1863. 

Grave«'» Clinical Med , 1843, p. 409. 

Colmer, London Med. Gaz , April 21, 1843. 

McCormac, Lancet, May* 27, 1843. 

R. Dt.herly, Dublin Med. Jour., vol. xxv, 1844, p. 82. 

West, Lect. on Dis. of Childhood, London, 1848. 

Richard (de Nancy), Bull, de Ther., Fevr. 1849, p. 120. 

39 



610 ATROPHIC INFANTILE PARALYSIS. 

It will be observed that the vague and discordant views which have been 
held in regard to its cause and nature, have led to the employment of 

Fliess, Jour. f. Kinderkr., July and August, 1849. 

Bellingham, Dublin Med. Press, 1850. 

Rilliet, Gaz. M^d. de Paris, Nov. 1851. 

W. Gull, on Paralysis during Dentition, in article on Value of Electricity as a 
Remedial Agent, Guy's Hosp. JHep., 2d ser., vol. viii, pt. i, 1852, p. 81. 

Little, on Deformities of Human Prame, London, 1853, p. 120. 

Rilliet and Barthez, Traite des Mai. des Enfants, ed. 2eme, 1854, t. ii, p. 545. 

Vogt, Essential Paralysis of Children, Berne, 1858, pp. 86 ; New York Journal 
of Med., Jan. 1859, p. 117. 

Eulenberg, on Essential Paralysis of Children, Yirch. Arch., 1859, 177 ; and 
Schmidt's Jahrb., vol. 107, p. 55. 

Bierbaum, Paralysis of Children, Jour. f. Kind., 1859, 1 and 2, p. 18. 

Copland, Diet, of Pract. Med., vol. iii, Amer. ed., 1859, p. 24. 

Valleix, Guide du Medecine Prat., ed. 4eme, 1860, t. i, p. 759. 

Brunniche, ii. d. sogennant. Essentiellen Lahmungen bei Kleinen Kindern., 
Jour. f. Kind., 1861. 

Echeverria, Atrophic Fatty Palsy in Infancy, Amer. Med. Times, July 18, 1861. 

Chassaignac, a Peculiar Porm of Infantile Paralysis, Med. Times and Gaz., Nov. 
9,1861. 

Duchenne, De I'Electrisation Localisde, Paris, 1861, p. 275. 

Smith, Paraplegia occurring in Young Children, induced by Wet and Cold, 
Lancet, 1861. 

Bouchut, des Maladies des Nouveaux-nes, etc., ed. 4eme, Paris, 1862, p. 122. 

Cornil, Comp. Rend, de la Soc. de Biologie, 1863, p. 187. 

Laborde, De la Paralysie (dite Essentielle) de I'Enfance, These de Paris, 1864. 

Jaccoud, Des Paraplegics, etc., Paris, 1864, p. 448. 

W. A. Hammond, on Organic Infantile Paralysis, New York Med. Jour., Dec. 
1865, p. 168 ; and Jour, of Psych. Med., vol. i, 1867, p. 49, and vol. ii, 1868, p. 581. 

Adams, on Club-Foot, London, 1866. 

Prevost, Comp. Rend, de la Soc. de Biologie, 1866, p. 215. 

C. Handfield Jones, Functional Nervous Dis. (Amer. ed.), Philada., 1867, p. 88. 

J. Russell Reynolds, Lancet, vol. ii, July 11, 1868, p. 85. 

C. B. Radcliflfe, Art. on Infantile Paralysis, Reynolds's Syst. of Med., vol. ii, 
1868, p. 661. 

T. Hillier, Diseases of Children (Amer. ed.), Philada., 1868, p. 255. 

S. Wilks, Lect. on Nerv. Dis., Med. Times and Gaz., Dec. 19, 1868, p. 689. 

Z. Johnson and J. Lockhart Clarke, Med. Chir. Trans., vol. Ii, 1868. 

Moritz Meyer, Electricity in Practical Medicine (translated by W. A. Hammond, 
M.D.), New York, 1869, p. 218. 

Niemeyer, Practical Medicine (Amer. ed.). New York, 1869, vol. ii, p. 338. 

Vogel, Diseases of Children (Amer. ed.), New York, 1870, p. 391. 

Charcot and Joflroy, Cas de Paralysie infantile spinale avec lesions des cornes 
anterieures de la substance grise de la Moelle epiniere, Arch, de Phys. Nom. et 
Path., 1870, vol. iii, p. 134. 

Parrot and Joffroy {id. loc), p. 309. 

Vulpian [id. loc). p. 316. 

Allbutt, T. Clifford, London Lancet, November 10th, 1870, p. 481. 

Damaschino and Roger, Gaz. Med., 1871, p. 457, and in Syd. Soc. Biennial Ret- 
rospect, 1871-72, p. 96. 

Rinecker, Berlin Klin. Woch., 1871, p. 627. 

Rosenthal, Centralblatt, 1872, p. 176, from Oestr. Zeitschr. f. prakt. Heilkund., 
1871, No. 52. 

Sinkler, Palsies of Children, Amer. Jour. Med. Sciences, April, 1875, p. 348. 



CAUSES. 611 

many uames by which to designate it. Thus it has boon eallod by Iloine 
iutautile spinal paralysis, and Moyer follows him in the use of this term ; 
by Gull it was called paralysis during dentition ; by Rilliet and Barthez, 
Vogt, Eulenberg, Valleix, Brunniche, Laborde, and Niemeyer, essential 
paralysis of children; by Duchenne, who is followed by Echeverria, fatty 
atrophic paralysis of iutaucy ; by Reynolds, paralysis with wasting of the 
muscles; by Bouchut, myogenic paralysis; by Hammond, organic infan- 
tile paralysis ; and it has also been called idiopathic and congestive infan- 
tile paralysis. 

We have been led to select the name which heads this article, because 
those above enumerated appear to us to be either vague and inaccurate, as 
the terms essential and idiopathic; or to neglect one of the most striking 
features of the disease, the muscular atrophy, as the term infantile sj)inal 
paralysis does; or to convey a partial or even erroneous theory of the 
pathology of the disease, as the names congestive and myogenic respect- 
ively do. The terms organic and fatty atrophic paralysis also seem to us 
defective, since the first is equally applicable to cases of palsy due to or- 
ganic disease of the brain, while the second is based upon the fatty degen- 
eration of the aftected muscles, which, however, occurs only in a portion 
of the cases of infantile paralysis. 

It is evident, however, that a term might be introduced which would 
embody our present accurate knowledge of the seat and character of this 
form of paralysis, and which should supplant all those above mentioned. 

Causes. — The etiology of this affection is very obscure, doubtless partly 
owing to the tact that, as the paralysis occurs when the spinal system is 
extremely impressible, the causes which induce it are trivial and usually 
entirely overlooked. Age is the only influence which can be said to have 
a positive action in its production, since the great majority of cases occur 
between the ages of six months and two years, during the period of 
primary dentition. By several of the early observers especially, the dis- 
ease was on this account attributed solely to dental irritation, but more 
careful observation shows that in most cases no such ilircct connection 
can be traced ; and it is probable that early age and dentition only act 
indirectly by inducing a remarkably susceptible condition of the entire 
t»pinal system. 

Sex appears to have no influence whatever upon its production ; and the 
disea.>*e is almost as frequent among the children of the wealthy as among 
the ill-fed and ill-tende*l children of the poor. In some few ca.**?, where 
the loss of power is sudden, the exciting cause seems to be the direct ex- 
posure to the l(K-al action of cold, a< from sitting upon a stone step (West), 
or lying on the damp ground (Hammond;. 

Atrophic infantile paralysis is usually primary, and occurs in the midst 
of gofKi health ; but it has also been obt*er\'ed in a secondary form, apfK'ar- 
iDg during the convalescence from mea.*ile8, scarlatina, or typhoid fever, or 
during rheumatism and chorea. 

In one of the cases following chorea, which are recorded by Kennedy 
{loe. cit.), it is positively stated that there was a distinct cardiac murmur. 



612 ATROPHIC INFANTILE PARALYSIS. 

due to organic valvular disease ; and it may be suggested that the essential 
cause of the parylysis was embolism of some of the spinal arteries, as ob- 
served by Pauum.^ 

Mode of Attack ; Initiatory Symptoms. — There is considerable va- 
riety in the mode in which this disease makes its appearance. In some 
cases the paralysis is the first symptom observed, and is found to have 
almost immediately attained its full extent, without any recognizable 
cause or premonitory symptom. Thus the child may have appeared per- 
fectly well when put to bed in the evening, and yet on the following morn- 
ing, there may be more or less complete loss of power over the lower 
extremities. But in the great majority of cases, especially the more 
severe ones, the attack is preceded by quite marked constitutional dis- 
turbance. This may consist merely of fever, appearing without evident 
cause and lasting from a few hours to a week or more, unattended by any 
gastro-intestinal disturbance. Or, during this period, the child may also 
complain of pain in the back, or there may be tenderness on pressure, espe- 
cially in the lumbar region ; there is frequently slight dulness of the mind, 
or finally, in comparatively rare cases, one or more convulsion may occur. 
It is the rule, however, for no marked symptoms of cerebral disturbance to 
be present at any period of the disease. There are rarely any symptoms 
connected with the parts about to become paralyzed, though in an interest- 
ing case recorded by Kennedy {loc. cit), there was spasm of the muscles 
subsequently affected. 

The disease usually makes its appearance during health, but it is proba- 
ble that many of the cases of paralysis occurring during convalescence 
from the various exanthemata properly belong to this variety. 

Whether preceded by initiatory symptoms or not, the development of 
the paralysis is generally sudden, and it is only in rare cases that it js par- 
tial at first and increases gradually. Indeed it usually happens that when 
first observed the paj-alysis is at its maximum, both as regards the number 
of muscles affected and the degree of the loss of power, and that there soon 
occurs a diminutian in its extent, so that only some of the parts first 
affected remain palsied. 

The form of the paralysis clearly indicates its spinal origin. Complete 
hemiplegia is scarcely ever observed, though in a few cases the arm and 
leg of the same side, or even all four extremities, have been palsied.^ 

1 Ueber den Tod durch Embolie (Bibliothek fiir Lager, 185G), quoted by Jaccoud 
(op. cit., p. 297), iind Arch. f. Path. Anat., xxv, 308, 443, 1863, in Yearbook of N. 
Syd. Soe., 1863, p 210. 

2 With reference to the parts affected, in 43 cases observed and analyzed by 
"West, in only 2 was the arm alone palsied, though in 19 instances the paralysis 
was limited to one or both legs. In 8 cases the right leg, and in 5 the left, was 
paralyzed ; and in one of the former instances paralysis of the right portio dura 
was also present. In 6 instances, the right arm and leg, and in 8 the left arm and 
leg, were affected, with which ptosis of the left eyelid was once associated, and once 
paralysis of the left portio dura. Paraplegia existed in 8 instances, combined in 
one case with paralysis of the right arm, and in another with loss of power over 



MUSCLES AFFECTED — SYMPTOxMS. 613 

Most frequently the disease takes the form of incomplete paraplegia ; 
though occasionally the paralysis affects single groups of muscles or eveu 
iudividual muscles. 

According to Mr. Adams, the groups of muscles most frequently affected 
are : 1. The muscles of the anterior parts of the leg, forming the extensors 
of the toes and the flexors of the foot ; 2. The extensoi-s and supinators of 
the hand, these muscles being always affected together; and 3. The ex- 
tensors of the leg, and with them generally the muscles of the foot, as in 
the first group. Wheu single muscles are affected, the most likely to suffer 
;ire these: 1. The extensor longus digitorum of the toes; 2. The tibialis 
anticus ; 3. The deltoid ; and 4. The sterno-mastoid. 

The bladder and rectum are very rarely involved. 

The degree of the paralysis varies as much as its extent ; usually com- 
plete at first, in some cases it soon becomes partial or even sliglit ; while 
in others the loss of power remains absolutely complete. The paralyzed 
muscles are perfectly relaxed, so that the affected parts cau have all their 
normal movements impressed upon them without difficulty, and fall in a 
lifeless manner if left unsupported. The special senses are unimpaired ; 
and general sensibility is usually only blunted for a time. Occasionally 
it is not affected at all, or, as stated by West, there may even be hyperies- 
thesia for a variable time. 

The paralyzed muscles are rarely the seat either of painful subjective 
-ensations or of tenderness on pressure ; though in some cases severe pain 
may be present in the affected parts. 

Reflex movements are, as a rule, abolished in those parts where there 
is complete loss of voluntary motion ; though Laborde (loc, cit.) has shown 
that they may occasionally be preserved even in the first stage of the 
paral}teis. 

During the early stage we are at present considering, the electro-mus- 
cular contractility usually remains intact, and the muscles respond both to 
the induced and direct current. 

The constitutional disturbances which we have described as preceding 
the paralysis may persist for a variable time after its development, or dis- 
:ir quickly, leaving no other symptoms present but those connected 
the paralyzed parts. 

The following case, seen by one of ourselves with Dr. James Tyson, 
may be quoted as an illustration of this form of paralysis. 

A male child, set. thirteen monthi*, was brought to Dr. Tyson for treatmont by 
it« molhfT, an intellieont woman, with govoral hoalthy children. The following 
Nislory of the case was obtained : The little boy had walked at the ai:«' of nine 
mr-nth?, and always* »eemed a viirorou.'i, intelligent child ; he had also cut eipht 
. without much irritation. Alnrnt Sept. lOlh, 1868, after no particular ex- 
f;, he became fretful and feverioh, with occaftional vomiting ; and after three 
days it was noticed that right-sided hemiplegia had developed itself. The paralysis 



lx>th delt^»id muscle.s, and over the flexor muscles of both thumbs. Six times none 
i»f the limbs were palsied, but the affection was confined once to the portio dura <»f the 
U*ft, and five times to the portio dura of the right side ; but in one of the»e instances, 
though there was no actual paralysis, the patient's gait was feeble and tottering. 



614 ATROPHIC INFANTILE PARALYSIS. 

of the arm was never complete, while the leg had entirely lost all power of motion. 
This loss of power had not become complete suddenly, but, at first partial, had 
gradually increased. There was no tendency to coma and no evidence of any 
acute pain. The febrile symptoms soon disappeared ; the arm regained the power 
of motion in a few days, but the leg remained palsied. It also soon grew remark- 
ably cold, and when seen on October 1st, three weeks after the attack, the tem- 
perature was decidedly lower than that of its fellow. Sensation was impaired, but 
had never been aboli'shed. There had been no paralysis of either bladder or rectum. 
At the time of the examination the child seemed bright and lively, though rather 
pale. There was no tenderness along the spine, nor in the leg. 'No reflex move- 
ments were developed in the paralyzed leg by tickling the sole of the foot. jSTeither 
atrophy nor deformity had as yet occurred. 

The subsequent course af the disease varies greatly in different instances. 
In one set of cases, though the paralysis may be quite extensive and com- 
plete at first, the symptoms gradually subside, the paralysis disappears, 
and complete recovery ensues in from four to six weeks. These cases 
correspond exactly to the form of paralysis originally described by Ken- 
nedy (loc. cit) under the name of " Temporary Infantile Paralysis," and, 
as we shall see hereafter, in all probability depend upon mere congestion 
of the spinal cord. 

In the other set of cases, on the contrary, the loss of power persists, and 
after it has continued for a time, varying from one to several months, is 
followed by marked and more or less rapid atrophy of the affected mus- 
cles. The circulation in the paralyzed parts becomes feeble, the sub- 
cutaneous veins are smaller, and Heine, and Rilliet and Barthez each 
cite a case of paralysis of the arm in which it was almost impossible to 
detect the radial pulse. The temperature of the affected part becomes 
perceptibly lower, the fall amounting, according to Hammond, to from 5 
to 8 or even 10 degrees,, as tested by a galvanometer. The muscles them- 
selves undergo marked atrophy, frequently accompanied by fatty degenera- 
tion ; and their reflex motility and electro-muscular contractility disappear. 
It is important to notice, however,, that long after muscular contractions 
fail to be produced by the induced current, they may frequently be excited 
by the use of a direct current of low tension, slowly interrupted. 

The mere wasting of the muscles is not, however,, the only cause of the 
great difference in size between the healthy and paralyzed members. The 
nutrition of the whole limb is affected, and the growth and development 
of all its tissues arrested, so that the paralyzed member becomes smaller 
in all its dimensions than its fellow. Rilliet and Barthez cite an example 
which they observed, to show to how remarkable a degree this conjoined 
atrophy and arrest of development may progress. The patient was a 
young girl who was seized with instantaneous paralysis of the right lower 
extremity ; and the following measurements show the degree of inequality 
which was produced by four years* continuance of the paralysis and arrest 
of development. 

Eight leg. Left leg. 

1. From thegreat trochanter to the external malleolus, 49 cent. . 54 cent. 5 mill. 

2. From the patella to the malleolus, . . . 29 " . 32 " 

3. Length of foot from heel to great toe, . . 14 " 3 mill. 18 " 



DURATION. G15 

Five months previously, the followinsr tliniinution in tliit'kness of the 
limbs was noticed : at throe fingeiV breadth above the pateHa, on left side, 
20 centimetres, 16 on r'mtht; at the middle of the thigh, on left side, 29 
centimetres, and 22 on right. The height of the child was 11(> eontim- 
etres. 

This wasting and palsy of the muscles is associated with relaxation of 
the ligaments, and the combination of these causes induces many of the 
deformities observed in childhood. "When the paralysis atlects one side of 
the body chiefly, it indirectly leads to various lateral curvatures in the 
spinal column, probably from a want of symmetrical action in the muscles 
of the two sides. 

In cases of paralysis of the arms, the relaxation of the ligaments about 
the shoulder-joint and the atrophy of the deltoid allow tlie head of the 
humerus to drop out of the glenoid cavity, so as to produce even complete 
dislocation, with apparent elongation of the paralyzed limb to the extent 
of three-fourths of an inch (West). 

As the muscles of the lower extremitie.s are far most frequently affected 
in this form of paralysis, we usually find the resulting deformities in- 
volving the feet and legs, where they constitute the greater proportion of 
all cases of club-foot. According to Adams (he. cif.), " these deformities 
occur in the following order of frequency: 1. Talipes equinus; 2, equino- 
varus; 3, equino- valgus ; 4, calcaneus, or calcaneo-valgus ; and 5, talipes 
varus. When both feet are affected, equino-varus of one foot is generally 
found with equino-valgus of the other." 

In addition to the influence which the actual wasting of the limb and 
the arrest of its development exert, Adams believes that the great cause 
of .such deformities is the " adapted atrophy" of Paget, the changes which 
ensue in consequence of the mechanical relations of the foot to the leg. 
Although, however, it is true that paralysis of a group of muscles does not 
excite active contraction in their opponents, it appears that in the efforts 
of the child to move the part, the non-paralyzed muscles must gain con- 
trol over the limb, and aid at lea.st in producing the various characteristic 
distortions. 

During the development of this atrophic stage, the general sensibility 
of the affected parts is usually normal, and the general health, intelligence, 
and nutrition of the patient unimpaired. 

DruATiox. — As will be inferred from our description of the course of 
this affection, the entire duration and that of its different stages varies 
greatly in different cases. In some, which have hence had the name 
"tenipf>rary" infantile paralysis bestowed upon them, the loss of power 
rapidly diminishes, and complete recovery folIf»WH in from a few days to a 
few weeks ; while, in other cases, the paralysis persists until atrophy ensues, 
and the limb may remain crippled and useless throughout life. The |)erifHl 
which elapses before atrophy commences, and the rapidity with which it 
advanres, also vary extremely, even in apparently similar cas^-s. Thus the 
palsied muscles may begin to atrophy within four or five weeks, though 
more frequently this change cannot be noticed for several months. Dif- 
ferent muscles also atrophy with very different rapidity, the deltoid and 



616 ATROPHIC INFANTILE PARALYSIS. 

tibialis aiiticus appearing to waste more rapidly than any other muscles 
of the body; and, in different cases, the same groups of muscles show 
equal variety in this respect, a few weeks serving^ some instances for as 
much wasting to occur as would requii'e months to produce in other cases. 

Prognosis. — The great uncertainty of the progress and duration of 
atrophic infantile paralysis render it highly desirable to ascertain, if pos- 
sible, the conditions which determine its result. Of itself, it is never 
fatal ; but, unfortunately, our prognosis is limited, in the early stage of 
the disease, to this assertion, for the duration and course of the case are 
not influenced, in any constant and reliable way, either by the age of the 
patient, the extent of the paralysis or the parts aflTected, or the initiatory 
symptoms. It may perhaps be stated that, in general, cases which are 
ushered in by high fever, especially if associated with convulsions, and in 
which the paralysis is extensive, will prove severe and tedious. But there 
are too many exceptions to every particular of this statement for it to be 
regarded as a general rule of much positive value in prognosis. 

When paralysis has lasted three or four weeks, we are able to determine 
with much accuracy the approach of atrophy by the condition of the 
electro-muscular contractility; for it has been frequently observed that 
those muscles which lose their power of responding to the interrupted 
current, soon begin to waste. 

After the occurrence of atrophy, also, much valuable aid in prognosis is 
gained from the use of electricity. 

We may here mention the interesting and highly important observation, 
first made in connection with this disease by Hammond (loe. cit.) and J. 
Netten Radcliffe,^ that in many cases where the atrophied muscles have 
lost entirely their power of reacting to the most powerful induced electri- 
cal currents, they will still react vigorously to a direct (galvanic) current 
of low tension and slowly interrupted. The importance of this discovery, 
in the treatment of the disease, can scarcely be overrated ; and it has also 
enabled this point to be established in the prognosis, that whenever mus- 
cular contractions can be excited by either induced or direct currents, no 
matter how far advanced the atrophy of the muscles, the restoration of 
their power can certainly be accomplished; though it would appear from a 
case successfully treated by Hammond, that even when such contractions 
are not at first produced, the prognosis is not absolutely unfavorable. The 
still more curious, and as yet inexplicable observation has also been fre- 
quently made, that as the muscles regain their power of voluntary motion, 
their susceptibility to the direct galvanic current is apt to diminish, but, 
on the other hand, their normal reaction to the induced current returns. 

The prognosis will also be materially influenced, especially when the 
atrophic stage has begun, by the condition in which the tissue of the palsied 
muscles is found, as in cases where advanced fatty degeneration is present, 
it is far more unlikely that they will ever regain their power. In order to 
ascertain this point, Duchenne has devised a small trocar/ called by him 

1 See footnote to page 665, vol. ii, Reynolds's System of Medicine. 

2 These trocars are manufactured by Tiemann, of New York. Dr. Hammond 
has published (Jour, of Psych Med., July, 1867) a description of their form and 
mode of use, illustrated by a woodcut. 






MORBID ANATOMY AND PATHOLOGY. 617 

" emporte-pi^ce," by which small j^iooes of muscle can be extracted, and 
subsequently submitted to microscopic examination. 

It is evident, finally, that the duration and result will depend, to a great 
extent, upon the period at which treatment is instituted. In those cases 
where the paralysis has been allowed to continue until marked atrophy has 
ensued, and the electro-muscular contractility is almost lost, althouu:lj the 
prognosis may still be favorable as regards the ultimate cure, it must be 
carefully guarded as to the duration, since the treatment will probably re- 
quire to be steadily pursued for many weeks, or even months. 

MoRP.iD Anatomy and PATnoLOGY. — It appears desirable to introduce 
the consideration of the anatomical appearances at this point, in order to 
facilitate the subsequent discussion of the pathology and diagnosis of the 
disease. 

In regard to the changes which take place in the atrophied muscles, 
the brief yet complete summary given by Hillier, may be (juoted {op. rit., 
page 268): 

" 1. The transverse striae become less apparent and separated l)y wider 
-paces, which are filled with opaque granules, which are not dissolved by 
ether, but are sensil)ly acted on by acetic acid. 

" 2. The transverse striaj disappear, and there is an abundant appear- 
ance of granular substance. 

"3. There remain but slight traces of longitudinal fibres, filled with 
granules, with a larger quantity of connective tissue between the bundles. 

"4. The granules have disappeared, and emply transparent tubes of 
myolemraa with a few scanty granules on their walls remain, with more 
connective tissue and some elastic fibres. 

"o. In some cases, fat-globules take the place of the granular matter in 
the muscular fibres, and in the cellular tissue between the bundles of mus- 
cular fibre. This change is not universally j)resent in cases even when 
atrophy has proceeded to an extreme degree." 

The last conclusion stated here, which has been confirmed by other ob- 
sers'ere, shows that perhaps the most frequent change which occurs, is a 
.simple atrophy of the muscles, with a granular but non-fatty degeneration, 
and conclusively shows the inaccuracy of the name proposed by Duchenne 
for the dis€a.*e ''namely, fatty atrophic paralysis of infants). 

In approaching the question of the lesions of the nervous centres in this 
affection, which have now been definitely determined, it is necessary to 
refer to the general question of the existence of so-called essential, purely 
neurotic paralyses. In one form of paralysis, the reflex, it is true that as 
yet no material lesion has been detected, and that the most plausible ex- 
planation of the loss of power in such ca«e8 is simply the exhaustion of the 
fiiiirtiunal activity of the spinal cord, owing to the prolonged irritation of 
r> •..](' of the peripheral nerves. And it muxt be borne in mind that the 
form of infantile paralysis under consideration was formerly by some re- 
garded as a reflex paralysis depending on dental irritation. Apart, how- 
ever, from the fact, that the symptoms much more closely resemble those 
due to spinal congestion than those seen in refl<-x fwiralysis, it is to he re- 
menjbered that the disease is by no meauji limited to the period of denti- 



618 ATROPHIC INFANTILE PARALYSIS. 

tion, and that all local signs of dental irritation are frequently absent at 
the time of the appearance of the paralysis. With the exception, then, of 
reflex paralysis, it may be asserted with confidence that all other forms of 
spinal paralysis are associated with some material lesion of this nervous 
trunk. It is to be remembered that it is only a few years since the beauti- 
ful researches of J. Lockhart Clarke have shown that positive structural 
changes, in both nerve-cells and nerve-fibrils, may be detected by micro- 
scopic examination in spinal cords, which present no alteration apparent 
to the naked eye. In rejecting the evidence of all post-mortem examina- 
tions of the spinal cord, made before the introduction of Clarke's method, 
as incomplete and inconclusive, we find that in all those diseases formerly 
classed as pure neuroses (such as tetanus and chorea), which have been 
subjected to this latter mode of examination, positive demonstrable lesions 
have at least occasionally been detected. 

Among this class of diseases, so long considered as purely functional 
neuroses, atrophic infantile paralysis has always, until lately, occupied a 
prominent position, as is evinced by the large number of authors who have 
described it under the terms " essential," or " idiopathic." 

It is indeed difficult to secure opportunities of examining the state of 
the spinal cord in this affection, owing to the fact that the disease is scarcely 
ever, if at all, fatal of itself; so that the arguments in opposition to the 
view of its functional nature, will be in part drawn from the close analogy 
of its symptoms to those of certain spinal diseases, which are well known 
to be attended with positive lesions of the nervous tissue. Thus, in its 
mode of appearance, and in the character of the paralysis, there is so per- 
fect a resemblance to the onset and symptoms of congestion of the spinal 
cord, as to leave little room for doubt that this is the condition at first 
present in many cases of atrophic infantile paralysis. In both this affec- 
tion and spinal congestion, the paralysis may appear quite abruptly, or be 
preceded by pains in the back and fever ; in both, the paralysis is usually 
paraplegic, the loss of power only partial, and the affected muscles are 
relaxed ; in both, general sensibility is but slightly impaired, the bladder 
and rectum are not involved, and there are no disturbances of the cere- 
brum or special senses; in both, finally, recovery usually follows, if proper 
treatment be promptly instituted. 

In those cases where the paralysis disappears within a few days or weeks, 
it has been supposed by various authors that the nature of the disease is 
entirely different from that of atrophic infantile paralysis ; but it appears 
to us highly unnecessary to complicate the question by such a supposition, 
since the temporary character of the paralysis is readily accounted for by 
supposing that the spinal congestion which produced it was slight and 
transient. 

It is quite possible also that in other cases the loss of power caused by 
more severe spinal congestion should persist until atrophy of the affected 
muscles ensued, and rendered the case more protracted. 

Indeed, some of the authors who most forcibly support the view of the 
pathology of this affeetion which we have given above, as Dr. C. B. Rad- 
cliffe {loc. cit.)j hold that the lesion of the cord does not advance beyond 



MORBID ANATOMY AND PATHOLOGY. 019 

this stage of congestion. The evidence in support of this opinion is prin- 
cipally found in the result of post-mortem examintitions, as tliose reported 
by Rilliet and Barthez, Fliess and Adams, Avhere no lesions of the cord 
were detected. But in none of these cases does it appear that the careful 
and skilful microscopic examination, which is now recognized as necessary 
to detect some lesions of the nervous tissue, was performed ; so that we 
may feel at liberty to doubt the complete accuracy of these autopsies. On 
the other hand, it certainly seems entirely consistent to suppose that in cer- 
tain cases, where the congestion is unusually marked and prolonged, or 
where it is repeated, that a process of subacute inflammation should be ex- 
cited, resulting in the permanent structural change. 

The usual change which takes place in the spinal cord, under such cir- 
cumstances, is that described under the name "sclerosis," in which there 
is marked proliferation of the connective-tissue elements of the cord, with 
swelling and consequent pressure upon the nerve-tubules. In the subse- 
quent development of the new-formed connective tissue, it undergoes con- 
traction, and induces atrophy of the compressed nerve-tubules. The por- 
tions of the spinal cord where this lesion exists, may either be atro}>hied 
or retain their normal size, shape, and external appearance, but on trans- 
verse section, though the tissue is firm, certain parts of the white substance 
are seen to present a grayish, translucent appearance, differing noticeably, 
in well-marked cases of the lesion, from the opaque whiteness of the sur- 
rounding healthy tissue. In other instances, however, the change in color 
cannot be detected, and it is only by microscopic examination that we can 
discover the increase in the connective tissue of the cord, and the atrophy 
of the nerve-tubules. 

This view of the nature of the lesions in atrophic infantile paralysis, 
was forcibly urged by Heine, in the last edition of his classical monograph 
on this subject (oj). cit.), who based it merely upon an analysis of the symp- 
toms, and it has since been adopted by Jaccoud (he. cit.). It does not 
rest, however, solely upon such reasoning, for there have been a limited 
but rapidly increasing number of autopsies made in which the above-de- 
f^ribed lesions of sclerosis have been actually observed. 

Heine quotes three post-mortem examinations in support of this theory. 
One of these, quoted from Longet, was of a girl of eight years, with club- 
foot on the right side, following an attack of paralysis, who died of variola ; 
and at the autopsy the muscles and nerves of the right leg were atroi)hied, 
and the anterior roots of the spinal nerves which make up the right sciatic 
nerve, were scarcely one-quarter the size of the corresponding roots on the 
left side. 

In the second case, quoted from Hutin, the subject was forty-five years 
old, had been paraplegic from the age of seven years, and had considerable 
deformity of the lower members; at the autopsy, after death from dysen- 
ter}-, there wa« atrophy of the lower part of the spinal cord. 

The third observation quoted by Heine, has been quottid more fully from 
the original source (Trans, de h Soc. Mfd. de Berlin^ Dec. 7th, 1862), by 
Jaccoud (op. cif., p. 450 t. It was the autopsy of a child with paralytic 
club-foot, reported by Berend and liemak, where the "spinal arachnoid 



620 ATROPHIC INFANTILE PARALYSIS. 

was found thickened by inflammatory product, and exercising such pres- 
sure upon the cord, that when the false membranes were cut, the nervous 
tissue immediately protruded through the incision." 

Berend also reported (id. loc.) another observation upon a child four 
years old, who died paraplegic with contraction of the legs and feet. The 
autopsy was performed by Recklinghausen, who found tubercles in the 
cord. 

Hammond reports (Jour, of Psych. Med., vol. i, p. 51) a case where the 
paralysis affected the left leg, and had lasted four years, in which he found, 
upon post-mortem examination, a cicatrix, partly, filled with clot, in the 
lower part of the dorsal region, in the left anterior column. Recently, 
however, the opportunities for careful study of the lesions in atrophic in- 
fantile paralysis have multiplied, and have been seized by numerous able 
observers, especially in France, where the first demonstration of the true 
characteristic morbid changes in this disease was effected. The earliest 
cases placed upon record in which this lesion was accurately described were 
by Coruil (loc. cit.) in 1863 ; by Laborde (loc. cit.), in 1864 ; by Prevost 
(loc. cit), in 1866 ; J. Lockhart Clarke (loc. cit.), in 1868 ; Charcot and 
Joffroy (loc. cit.), in 1870 ; Parrot and Joff'roy,^ in 1870 ; Roger and Damas- 
chino,' in 1871 ; Dujardin-Beaumetz,^ in 1872 ; Petitfils,* in 1873 ; and 
numerous other observers have followed in confirmation, so that the morbid 
anatomy of atrophic infantile palsy may be regarded as clearly and fully 
determined. 

The lesions occupy the antero-lateral columns, and especially the an- 
terior horns of gray matter. There is atrophy of the nerve-fibres in the 
anterior and lateral columns, which varies in amount in different cases, 
and is associated with a varying degree of hypertrophy of the interstitial 
connective tissue (sclerotic). These parts are more translucent than nat- 
ural, and often present a very appreciable grayish rose tint to the naked 
eye. The consistence of the affected tracts is diminished, and upon micro- 
scopical examination there may be observed a marked proliferation of 
the elements of the connective tissue, the cells and nuclei being dispersed 
in the midst of a finely granular substance, in which there are fibrils of 
extreme tenuity. In the parts which are most affected the nervous 
tubules are either lost altogether, or they present a varicose appearance, 
while the other portions of the spinal column preserve a perfect integrity. 

But the most characteristic changes are found in the anterior horns of 
gray matter, where there is invariably atrophy of the ganglion nerve-cells 
and of their processes, so that in some instances the anterior group of cells 
has entirely disappeared from atrophy. In other cases the remains of the 
cells are found atrophied, misshapen, and with granular degeneration of 
their contents. The other elements of the gray tissue are usually changed 
also ; there is proliferation of the nuclei of the neuroglia, and occasionally 

1 Arch, de Physiologie, torn, iii, 1870, p. 135. 

2 Gaz. Med. de Paris, 1871. 

3 De la myelite aigue, Paris, 1872. 

* Considerations sur I'atrophie des cellules motrices, Paris, 1873. 



DIAGNOSIS. 1)21 

increase in the delicate fibrils of this connective tissue. In some cases 
the walls of the vessels in the aHected parts are found thickened, with 
proliferation ot^ their nuclei. These chauixes have been so prominent in 
some case^ as to have led ta the opinion (.Damaschino, Duchenne) that 
they constituted the primary and essential lesion. This, howtver, does 
not seem probable. 

It is thus seen that the progress of anatomical investigation ha:^ at last 
developed the true pathology of this atiection. It is possible that in some 
cases the lesion of the anterolateral columns may be the result of hajmor- 
rhage into the substance of the cord, or of pressure from thickening of 
the meninges ; but in the vast majority of cases the morbid proccs^s is one 
of slow subacute inflammatory, sclerotic change, with atrophy of the nerve- 
tubules in the antero-lateral columns and anterior horns of gray matter, 
and especially with atrophy and destruction of the anterior groups of gan- 
glion nerve-cells. 

Diagnosis. — There is but little danger of overlooking the nature of 
those cases where the paralysis appears quite suddenly in the midst of ap- 
parent good health, excepting in cases occurring in young children who 
have not yet learned to walk, and where the loss of power is limited to 
the lower extremities. In such instances the paralysis may be entirely 
overlooked by the parents or nurse for some time. So also in cases pre- 
ceded by constitutional disturbance, as there is nothing whatever charac- 
teristic in these premonitory symptoms, it is quite possible to fail to rec- 
ognize the presence of j)aralysis. It is well, therefore, whenever a child 
between six months and three years of age presents feverish symptoms for 
which no apparent cause exists, to ascertain carefully whether there is 
any loss of power of its extremities. 

The diseases with which atrophic infantile paralysis is most likely to be 
confounded, are other forms of paralysis of cerebral or spinal origin, and 
progressive muscular atrophy. 

In paralysis due to haemorrhage into the substance of the brain (see 
page 520 J, the case is more apt to be ushered in by delirium or convul- 
sions, followed by more or less marked coma, while in atrophic infantile 
j-nralysis there is either entire absence of cerebral symptoms, or at most a 
-;: _lc convulsion occurs. Cerebral paralysis is usually hemiplegic, while 
in the form of spinal paralysis we are considering, paraplegia is more 
common, or the loss of power may be limited to one leg or to a single 
group of muscles. In those comparatively rare cases where the paralysis 
is at first hemiplegic, the arm usually soon regains its power of motion, 
leaving the leg paralyzed ; while the reverse of this occurs in cerebral 
hemiplegia, where the leg usually improves much more rapidly than the 
arm. In cerebral paralysis, also, the affected raui*cles are frequently 
rigid instead of being relaxefl ; and there is not the tendency to atrophy 
and deformity, the loss of electro- muscular c*)ntra('tility, nor the hiwering 
of the teraj>erature of the affrct« d part, whirli arc ob-rrv.d in atrophic 
infantile paralysis. 

In cases of meningeal ap^^iph-xy wniir im- iiiiiii«iiiiiii;.'i- mi" <»< i iirr«d 
upon the surface of the brain, the symptoms are still more <listincl. Thus 



622 ATROPHIC INFANTILE PARALYSIS. 

(see page 520) there are usually repeated convulsive seizures, with somno- 
lence during the intervals; paralysis is rare and partial, while strabismus 
and tonic contraction of the hands and feet are very common. 

In acute inflammation of the spinal cord, or myelitis, the loss of power 
is complete, and there is also more marked loss of sensation, and paralysis 
of the rectum and bladder, with alkaline urine ; though there is here as 
well as in atrophic infantile paralysis, diminution of reflex excitability 
and electro-muscular contractility, and wasting of the paralyzed muscles. 
The symptoms first mentioned, the more grave character of the case, and 
the tendency of the paralysis to increase rather than decrease, suffice to 
distinguish m3'^elitis from the affection under consideration. 

Progressive muscular atrophy, of very rare occurrence in children, may 
be distinguished by its gradually progressive course ; and by the pres- 
ervation of the temperature of the affected parts, of the power of motion, 
and of electro-muscular contractility, until atrophy has far advanced. 
There is usually a quivering of the atrophied muscles in this disease, due 
to fibrillar contraction, which is entirely wanting in atrophic infantile 
paralysis. 

AVe have already expressed our belief that some of the cases where the 
loss of power is very temporary, are really instances of reflex paralysis, 
and in such some source of peripheral irritation can usually be detected. 

West alludes to the fact that in those cases where the affection is limited 
to one leg, and attended by hypersesthesia and painful sensations, the dis- 
ease may be mistaken for coxalgia, though the diagnosis may readily be 
made by attending to the slow course, the absence of paralysis, the fixed 
pain in the knee-joint, and the marked increase of suffering caused by 
forcing the head of the femur against the acetabulum, which characterize 
hip-disease. 

Treatment. — The treatment of atrophic infantile paralysis may be di- 
vided into that adapted to the early stage and that directed against the 
second stage or period of atrophy. 

In the first instance we must endeavor to discover and remove any ex- 
citing cause of the paralysis that may exist. If symptoms of morbid denti- 
tion have preceded, and the appearance of the gums indicate it, they should 
be lanced ; or if gastro-intestinal disturbance is present, or the presence of 
worms is suspected, laxatives should be administered. Tepid baths are 
also recommended, as tending to allay irritation and reduce feverishness. 

When, however, no local irritation can be detected to render it possible 
that the case is one of reflex paralysis, we should direct our remedies to- 
wards relieving the spinal congestion, which we believe to exist in cases of 
true atrophic infantile paralysis. Counter-irritation should be applied 
along the spine, and may be eflfected by producing a narrow blister, or 
preferably by the use of sinapisms or stimulating liniments, containing 
croton oil, ammonia, or turpentine. 

Local abstraction of blood by means of cups or leeches applied along 
the spine has been recommended by Fliess ; and we should certainly ad- 
vise its employment, especially in those cases where there is considerable 
febrile disturbance and pain in the back. 



TREATMENT. 623 

There are also certain remedies from which wo have obtained cxtoUent 
results in the treatment of spinal concrestion in the adult, and sliould, 
therefore, recommend their employment in the early stage of this atiection. 

These are ergot, which may be given in the form of fluid extract, begin- 
ning with doses of 5 to 10 minims for a child of two years old ; and bel- 
ladonna, which may be given either in the form of tincture, or an aqueous 
solution of the extract. Iodide of potassium may also be given in combi- 
nation with one or the other of these, in doses of gr. j or ij for a child of 
two years old, in the hope of preventing the development of any iuHam- 
matory changes in the cord. 

In addition to these remedial measures, the child should be absolutely 
confined to bed. 

If, despite the use of these agents, the paralysis persists, the temperature 
begins to tall, and the muscles to atrophy, every means must be adopted to 
promote the general nutrition of the child so as to favorably influence in- 
directly the changes in the spinal cord ; and, at the same time, local treat- 
ment must be instituted to promote the circulation and nutrition of the 
paralyzed j)arts. 

Among the internal remedies, iron is one of the most suitable, and may 
be given in any eligible form. The pyrophosphate is perhaps especially in- 
dicated on account of the phosphoric acid with which the iron is combined. 

The various preparations of nux vomica or its alkaloid strychnia are 
also v-ery valuable after the acute stage has passed. Heine advises the 
use of tr. nucis vomicae in combination with camphor and pyrethrum ; 
while West recommends the alcoholic extract of nux vomica. Strychnia, 
which is more frequently employed than the preparations of nux vomica 
itself, is usually given in the form of solution. Hiller has also used it 
hypodermically, but without marked benefit. 

The doses of these powerful drugs, which are recommended by some 
authors, especially Heine, appear to us too large to be safely administered. 

We should recommend beginning with a dose of at most gtt. ij of the 

tincture, or gr. s'^th of the alcoholic extract of nux vomica, or gr. s'oth of 

sulphate of strychnia, for a child of two years old ; the amount being in- 

-^•d steadily but cautioasly so long as no unpleasant symptoms are 

iuce<l by it. 

Local means must also be employed for inducing increased circulation 
in the affected parts. For this purpose, the stimulating liniments already 
mentioned, or moist heat, may be applied. Pa.ssive motion, and kiuarling 
the muscles, also aid in improving their nutrition and contraetile power. 

Electricity, however, certainly ranks first among the local means for re- 
storing the contractile power of the paralyzed muscles. It is true that 
• . lal authorities have a-^iserted that they derived no gocMi results from 
iiiployment, but since the intro<luftion of loealized electricity (faradiza- 
tion), as developed by the researches of Duchcnne, and of the use of the 
constant current, the most marked benefit I.m- 1.. < n ol)tained at all stages 
of this form of paralysis. 

If the induced current be used, it must be cureluily i.-<olated and limited 
to the aflfected muscles, by means of wet sponges fastened to the electrodes. 



624 ATROPHIC INFANTILE PARALYSIS. 

In those cases where the muscles refuse to respond to an induced current 
even of considerable power, the direct current, slowly interrupted (the 
labile current of Remak), will be found to induce contractions, excepting 
w^here the muscular tissue is far advanced in fatty degeneration. In all 
such cases then, this direct current should be employed. We have already 
alluded to the curious observation which has been made by several authors, 
that as the palsied muscles regain their power under the use of the direct 
current, they respond to it less and less strongly, while the induced current 
is found to again have the power of exciting muscular contractions. "When 
this period in the treatment of the case arrives it is properly desirable to 
substitute the use of the induced current. 

In order that the use of electricity, in either form, may be productive 
of the excellent results it is capable of yielding, it must be applied thor- 
oughly to each of the paralyzed muscles three or four times weekly, and 
this treatment pursued for mouths, until the muscles regain both their size 
and contractile power.^ 

One of the earliest symptoms of improving nutrition is an elevation in 
the temperature of the part, which may readily be detected by the gal- 
vanometer, as before mentioned. The value of this mode of treatment is, 
indeed, so great " that so long as muscular contraction can be induced, 
recovery is merely a matter of time, but if no action of the paralyzed mus- 
cles can be brought about, the prognosis must be unfavorable, though even 
here there is some hope." (Hammond, Radcliffe.) 

In addition, however, to the local and general measures above recom- 
mended, there is another kirrd of treatment scarcely less important, which 
should be employed in conjunction with them. 

This consists in the use of such mechanical apparatus and gymnastic 
exercise as shall tend to bring the affected muscles into play, and to ob- 
viate the deformities of the atrophic period. The greater part of our 
knowledge upon this subject is due to the admirable and extensive obser- 
vations of Heine, who has the superintendence of a large orthopedic insti- 
tute, and has most carefully studied the effects of these agents upon cases 
of paralysis which have progressed to the stage of atrophy and deformity. 
But it is by no means to this advanced stage alone that such measures are 
adapted, for it is a matter of the highest importance, that from a very early 
period of the paralysis, the little patients should be subjected to this treat- 
ment. 

If the legs be affected, it is not surprising that the child, who has, per- 
haps, gained but imperfect use of its limbs, and is making its first essays 
in walking when the paralysis appears, should feel such a sense of in- 
security, even when the power of motion has returned to a considerable 
extent, that it will refuse to make any renewed efforts to walk. And the 

* For a full description of the best forms of electrical batteries for medical pur- 
pose«, the reader is referred to some of the manuals on medical electricity, as 
Meyer, Tibbits, etc. 

The best batteries in the American market are made by Fleming & Talbot, of 
Philadelphia, or by the American Galvano-faradic Manufacturing Company of 
]Sew York. 



GYMNASTIC AND MECHANICAL TREATMENT. 625 

parents, finding all their attempts to j^ersuade or compel it to do so un- 
availing and distressing to the child, are apt to desist, waiting until in- 
creased power of movement returns: a delay which is too often followed 
by all the steps of the atrophic period. 

Ti» supply the indispensable exercise of the muscles, and in a form 
attractive to the little patients, numerous meihanical contrivniuvs jiave 
been resorted to. 

While the legs are still almost powerless, some form of lnil\v -jumper at 
the Siime time delights the child and eflectually exercises its limbs. When 
the power of motion has returned to a somewhat greater extent, we gain 
the same results even more completely by the use of the go-cart or veloci- 
pede, a frame or a chair upon wheels, the motive power being furnished 
by the alternate pressure of the rider's feet upon a pair of treadles which 
are connected with the wheels by cranks. This imparts such a sense of 
ecurity and so much pleasure, that the child can readily be encouraged 
to take enough exercise to preserve the play of the articulations, and to 
aid in developing muscular power. 

Dr. West makes a single objection to the use of the go-cart ; that it 
♦encourages the tendency to leiin very much forward in walking, which 

Iways exists until after the little patients have learned to walk pretty 
well; he, therefore, advises that, after the child has gained some facility 
in the use of the go-cart, a jacket should be worn, supplied with a stout 

rap before and behind, so that the attendant can conveniently hold them 
;iud support the child's weight more or less completely, thus enabling it to 
walk without being thrown forward as when stepping in a go-cart. 

In children of from five to seven yeai-s even, the use of crutches is soon 
I'-quired, and it is desirable, so soon as possible, to abandon the other con- 
rivaoces spoken of, and trust the child to its own exertions to walk with 
i pair of crutches. 

When the paralysis affects the arras, precisely the same principle should 
_iiide us, and every form of persuasion, of stratagem, and contrivance, 

lUst be used to induce the child to exercise the crippled member. Trun- 
iling a hoop, or raising a weight by roeans of a cord passing over a pul- 

V, furnish good exercise to the arm ; or we may encourage the little one 

• use a contrivance, also called a velocipede, in which the wheels are 

irnetl by handles, instead of treadles, attached to the cranks. 
In addition to these forms of exerci.'»e, however, it is often found neces- 
sary to employ splints of different kinds, such as Stnmicyer's, which enables 

he angle of the splint to be changed without removal from the limb, and 
various modes of extension to counteract the tendency which exi.xU* to 

mtraction of the jmralyzed part. In some cases, indeed, all means are 
'^less to avoid this consefjuence, and we an? ohligc»d to resort to the 
M of the tendons of the contra«t<'d mu-^rh-* and subsequent extension, 

hough tenotomy should not be performe<l until time has l)een allowed to 
show the extent of permanent paralysis, and until the conjoined umc of 
electricity and orthopedic apparatus has proved iosuflScieut to restore the 
!irab to its shape. 

It mav readily be surmi-*e<l that ihi- orthopedic plan of treatment i« 



626 FACIAL PARALYSIS. 

one requiring the utmost patience and persistence, and the most loving 
persuasion and encouragement ; for, indeed, it must be pursued, in face of 
all apparent failure, for months and years. Nor must we be satisfied 
during this period with these efforts we are making to restore the power 
of the muscles ; but careful attention must be paid to the nutrition and 
general health of the child, and we must continue the use of the warm 
douche, in conjunction with the persistent use of* electricity, of stimulating 
frictions, and of every remedy calculated to promote the general nutrition 
of the child. 



ARTICLE XII. 

FACIAL PARALYSIS. 

Paralysis of the muscles supplied with motor power by the facial 
nerve, is frequently met with as a temporary condition in infants who 
have been delivered by forceps, as a result of the pressure of the blade 
of the instrument upon the nerve as it emerges from the cranium. It 
is by no mfeans rare, however, during childhood, and either appears sud- 
denly after exposure to cold, when it is possibly due to pressure caused by 
congestion and swelling of the tissues around the stylo-mastoid foramen ; 
or more gradually, when it is usually due to pressure from an enlarged 
gland, or to disease of the petrous portion of the temporal bone. 

The symptoms of this affection are so striking that no difficulty can 
exist as to its diagnosis. The eye upon the affected side remains open ; the 
power of knitting the forehead and of raising the eyebrow is lost; the 
angle of the nose and mouth on the same side hang down. The tears 
trickle over the cheek, and the conjunctiva frequently becomes injected or 
inflamed ; saliva dribbles from the mouth, portions of food collect between 
the teeth and paralyzed cheek, and there is inability to whistle, spit, or 
distend the cheeks with air. During the acts of laughing or crying, the 
face becomes distorted, owing to the immobility of the paralyzed side, 
while the antagonistic muscles act strongly and draw the features towards 
the sound side. 

In addition to these symptoms, which are common to all cases of facial 
palsy, there are others which depend upon the point at which the lesion 
involves the trunk of the facial nerve. Thus if the nerve be paralyzed 
between its point of emergence from beside the pons and the point where 
it gives off its petrosal branches (soon after entering the Fallopian canal), 
there will also be paralysis of one side of the soft palate, greater acute- 
ness of hearing on one side, and loss of the sense of taste on one-half 
the anterior part of the tongue. This latter symptom is due to the im- 
plication of the chorda tympani branch. If, therefore, the seat of the 
lesion is in the Fallopian canal between the points of origin of the pe- 
trosal branch and the chorda tympani, the palate will not be paralyzed, 
but the sense of taste will be lost. 



FACIAL PARALYSIS. 627 

It Is usually true that if the nerve be paralyzed before the origin of the 
stai>e(iius branch, the hearing becomes more acute; but in children the 
cause of the palsy is so often necrosis of the petrous portion of the tem- 
poral bone ass^ociated with disease of the internal ear, that there is fre- 
quently deafness with purulent otorrha^a. Finally, if the point of paraly- 
sis be near the stylo-mastoid foramen and below the chorda tympani, none 
of the above symptoms will be present, and there will only be the pal.^y of 
the external muscles already indicated. 

The possibility of mistaking simple facial paralysis for hemiplegia from 
cerebral disease must be borne in mind, though attention to tlie symptoms 
of the case will prevent any error in diagnosis. Thus in hemiplegia of 
cerebral origin, the paralysis is usually ushered in by convulsions and 
coma; the frontalis and orbicularis oculi muscles are not paralyzed; the 
sense of taste is not affected, but, on the other hand, the masseters, tempo- 
rals, and pterygoids, supplied by the fifth nerve, occasionally are para- 
lyzed, and the tongue is protruded towards the paralyzed side; and, 
finally, there is loss of power in the arm and leg on the same side. 

Webber ( Chicago Jour, oj JS'ervows and Menial Di^ea^'^e, July, 187<), }). 
363) records several interesting cases where the facial palsy appeared after 
convulsions, and while the paralysis of the arm and leg was very transient 
so as to have passed away before the case came under observation, the loss 
of power of the muscles of the face was persistent, and was associated with 
impairment of electro-muscular contractility. In these unusual cases the 
author thinks the lesion was in the brain, affecting the centre of innerva- 
tion for the facial muscles, which the researches of Hitzig and Ferrier 
tend to locate in the lower part of the central ascending convolution. 

The prognosis of cases of facial palsy must evidently depend upon the 
cause. When the paralysis is due simply to exposure to cold, a cure may 
be expected, though the affection is often very tedious, the paralysis at 
times persisting for months. But when, on the other hand, it depends 
upon disease of the temporal bone, the prognosis is usually unfavorable. 

The treatment must also be modified according to the cau.se of fh<' at- 
tack. 

In simple acute ca-^es, the application of hot fomentations to the part, or 
of one or two leeches near the stylo-ma.stoid foramen, should always be di- 
rected, and is often productive of good results. Later in the afll»ction, if 
the paralysis persists, small blisters should be repeatedly applied near the 
point of exit of the nerve. 

Electricity is here also of very great .service, and the same curious 
observation, which was mentioned in atrophic infantile paralysis, as to 
the pr)wer of the direct current to excite muscular contractions when 
th'- muscles have cea«!ed entirely to respond to an induced current, has 
Ih.ii frei|uentlv made in this aff*ection ( Baierlacher, Neumann, Hadcliffe, 
Hillier;. 

In addition to these local remedied', the internal use of strychnia, iron, 
or iodide of potas.*«ium, is often followe<l by benefit. In cases where there 
is reason to suspect that disease of the bone, or scrofulous enlargement of 



628 PROGRESSIVE MUSCULAR SCLEROSIS. 

the cervical glands, are the cause of the paralysis, the patient should be 
put upon the use of iodide of iron or cod-liver oil. 



AKTICLE XIII. 

PROGRESSIVE MUSCULAR SCLEROSIS OR PSEUDO-HYPERTROPHIC 
MUSCULAR PARALYSIS. 

Definition. — This curious affection is characterized by progressive loss 
of power, which first appears in certain groups of muscles, and advances 
until nearly all the muscles of the body may be involved, while at the 
same time the affected muscles increase in size and firmness owing to ex- 
cessive hypertrophy (sclerotic) of their interfibrillar connective tissue. 
The muscular fibres usually present changes themselves, and at a later 
stage there is a process of fatty degeneration or accumulation in the 
newly-formed interstitial tissue. 

History; Synonyms and Frequency. — True progressive muscular 
atrophy is extremely rare in young children ; and among the cases which 
have been described, as by Meryon,^ a certain number seem to belong to 
the disease now under consideration. The merit of having first clearly 
recognized and described the distinctive features of this latter affection, 
certainly belongs to Dachenne, whose first observations were published 
more than twelve years ago.^ Since then cases have been reported in rapid 
succession until the number now upon record must exceed 100. The dis- 
ease cannot therefore be regarded as a very rare one. There have been, 
we believe, but nine cases placed upon record in this country: one by Drs. 
Ingalls and Webber,^ by one of ourselves,* by S. Weir Mitchell,^ by E. M. 
Estrazulas,^ and by Dr. C. T. Poore -^ two by Dr. George S. Gerhard,^ and 
two by Dr. W. A. Hammond.** We have had an opportunity of carefully 
studying four of these cases. 

Various names have already been applied to the affection. It was origi- 
nally called "hypertrophic paraplegia of infancy," by Duchenne, but he 
has since substituted the terms, paralysis with muscular sclerosis (paraly- 
sie myosclerosique), or muscular paralysis with apparent hypertrophy 

1 Pract. and Path. Eesearches on Paralysis. London, 1864, p. 200, et seq. 

2 De I'Electrisation Localisee, 2eme ed., Paris, 1861. 

3 Boston Med. and Surg. Journal, Nov. 1870. 

4 Clinical Lecture on a case of Progressive Muscular Sclerosis, by William Pep- 
per, Philadelphia Med. Times, June 15th and July 1st, 1871. 

° Photographic Review, October, 1871. 

6 Obstetrical Journal of Great Britain and Ireland (American Supplement, p. 
81), Sept. 1873, vol. i, No. 6. 
' New York Medical Journal, June, 1875. 

8 Philadelphia Medical Times, October 16, 1876, p. 29. 

9 Dis. of Nervous System, 6th edition, 1876, p. 492, et seq. 



CAUSES — SYMPTOMS. 629 

(paralysie musculaire pseudo-bypertrophique\ It lias also been called 
''lipomatosis luxurians musculorum progressiva" i Heller); lipomatous 
muscular atrophy ^Seidel) ; progressive muscular paralysis, as a result of 
hypertrophy of the interstitial fatty tissue (Niemeyer) ; fatty muscular hy- 
pertrophy (^Bergeron and Lutz) ; }^eudo-hypertrophic spinal paralysis 
'Hammond^; and, finally, progressive muscular sclerosis (Jaccoud and 
others). We much prefer this latter term, since it expresses the true 
pathological process which is prej?ent, and at the same time does not tend 
to confound this disease with any of the forms of true paralysis, from which 
it is, in reality, clearly distinguished by the facts that it^ essential feature 
is a progressive change in the structure of the muscle, and that the loss of 
power is dependent upon the change in the muscular tissue, and is not pri- 
mary, as in all true palsies. 

Causf>. — The essential causes of progressive muscular sclerosis are un- 
known. There are, however, some influences which exert marked control 
over its occurrence. One of the most important of these is early age, since 
in a very large majority of cases the disease begins in childhood, and has 
even appeared in some cases to be congenital (Niemeyer). Although, 
however, it must be distinctly classed among the affections of childhood, 
it has been shown (Benedikt, Lutz, and Laycock) to occasionally occur in 
:t'! It life. Sejc also exert-s a powerful influence: of 4o case^ collected by 
\\-- razulas ijoc, cit.), in which this point was noted, it occurred only 7 times 
in females. 

The curious fact has also been observed, that several children in the 

-anie family are apt to be aflJ*ected, probably indicating some hereditary 

ucy. Eulenburg' is consequently inclined to regard the disease as 

^, -ijdent upon some congenitally defective formation of the central nervous 

-ystera, probably in the cells of the gray substance of the spinal cord. In- 

fs are on record where four brothers were affected (Meryon); and in 

iier two brothers (Euleuburg) ; and in still another by the son of the 

latter author, in which the affection first showed itself in three nisters suc- 

cesgively in the eighth year of their age. 

SYMiTO>L*i. — The disease either begins in early infancy, and is first mani- 
fested at the time the child should Ix'gin to walk, or it makes its appear- 
ance some years after the power of walking has been acquired. 

The disease usually affects first the muscles of the legs, and advances 
upwards; in Xiemeyer's case, on the other hand, it began in the gluteal 
muscles, and subsequently affected all the muscles of the lower extremities. 
The early symptoms are, therefore, connected with walking, and it is ob- 
served either that the child does not begin to walk until very late, and 
then walks imperfectly, or that, having walked well for several years, he 
• _'ii3 to be readily tired by standing or walking, and soon presents pccu- 
i ities in his gait. In a few instances, pains in the limbs have been com- 
plained of ID the early stage. When the disease is fully established, though 
before it has advanced far, the rao<ie of walking aud standing are quite 
characteristic. The patients find that, without some support, thrrsc ojjera- 

> Vircbow't Arcbiv, liii, S61. 



630 PROGRESSIVE MUSCULAR SCLEROSIS. 

tioiis become more and more difficult and painful, and that they are sub- 
ject to frequent falls. In order to maintain their equilibrium while stand- 
ing or walking, the lower dorsal and lumbar spine is arched forwards, 
while the upper part of the spine, the shoulders and head are bent back- 
wards, frequently to so great an extent that their point of equilibrium falls 
behind the pelvis, thus producing the deformity known as "ensellure" or 
" saddle-back." The legs are widely separated, and in walking the body 
is inclined laterally towards the leg which rests on the ground, thus pro- 
ducing a characteristic balancing of the body during progression, while 
the arms are swung about, and the legs are advanced by jerks, describing 
a small arc. 

While this impairment of strength and power of progression is develop- 
ing, the affected muscles undergo remarkable changes. For a time they 
may be noticed merely to cease developing and increasing in size, or, more 
rarely, as in the case reported by one of ourselves {loc. cit.), and which is 
quoted below in full, they may present a well-marked stage of atrophy. 
After the stage of muscular weakness has lasted for a variable time, from 
a few months to two or even three years, whether or not there has been 
any noticeable atrophy of the affected muscles, a progressive enlargement 
of them makes its appearance. This usually affects the gastrocnemii first, 
then the glutei, the lumbar muscles of the spine, of the' trunk, and finally 
the muscles of the arms, and even of the face and tongue. In five of the 
recorded cases, the heart has been hypertrophied. In one of these, reported 
by Dr. B. W. Foster, quoted by Poore (loc. cit.), the heart was normal when 
first examined, but three years later, and without apparent cause, it was 
found to be enlarged. 

The above order is not invariably followed, and in by no means every 
case is the affection of the muscles so universal. The apparent hypertro- 
phy may occur in nearly all the muscles which have shown weakness, but 
in general, according to Duchenne, it does not, and may even be limited 
to a very small number of them. The same observer {loc. cit), thus de- 
scribes the appearance of the muscles after this consecutive enlargement 
has occurred. 

..." The hypertrophied muscles are firm and elastic ; they become very 
hard while they contract, and show all the relief or projection which prop- 
erly belongs to their contracted state ; .they then appear to form a hernial 
protrusion through the integument, which is very thin ; moreover, their 
great size shows off the apparent smallness and delicacy of the joints at 
the knee, ankle, etc." 

When this pseudo-hypertrophy is marked, and afl^ects many muscles, it 
gives a most curious appearance to the children. Niemeyer speaks of his 
patient as looking "as if he had the body and head of a weak child on 
the hips and thighs of a strong man ; " and J. Lockhart Clarke, in de- 
scribing one of Duchenne's patients, says: " He looked like a little Her- 
cules. Every visible muscle of the body, except the pectorals, was enor- 
mously developed ; his head, even, appeared swollen, and the temporal 
muscles stood out like convex shells. Yet, when the poor boy attempted 
to walk, he labored to get along, presenting the most grotesque appear- 



SYMPTOMS. 631 

ance ; and when laid on the ground, ho was wln^lly unahle to rise hy liis 
own nnaided effort;?." ' 

Dr. Mitchell (/oc. cit.) chills attention to the faet, however, which W(> have 
also observed, that the enlargement of the calves is lower down than would 
be the case in excessively developed, but well-formed limbs. 

The marked enlargement of the muscles of the calves is often attended 
with forced extension of the feet, producing double pes equinus or ecjuino- 
varns. In the ease reported by Estrazulas {loc. cif.), there is also marked 
enlargement and retraction of the posterior muscles of the thigh, with 
atrophy of the extensor group, so that there is forced flexion of the legs, 
rendering the boy unable to stand at all. Knoll ^ also describes such con- 
tracti(»ns in the enlarged muscles, but they are not usually present. Ac- 
cording to Berger,' fibrillar contractions are of constant occurrence in the 
aflTected muscles : this does not accord with our own observations, nor with 
many of the reported descriptions of the disease. In one of the cases re- 
ported by Gerhard (loc. cit.) there was constant tremor of the flexors of 
the legs and feet, and of some of the muscles of the forearms. 

The electrical condition of the afl^ected muscles is peculiar. Frecjuontly 
the results, when tested with faradaic currents, are different from those ob- 
tained with galvanism. The results also vary at difterent stages of the 
same case. Usually the muscular contractility, as tested by faradization, 
is impaired in all the affected muscles, those whicli are hypertrophied, how- 
ever, contracting more actively than those which are atrophied. The gal- 
vano-contraetility is also slightly impaired. The electro-muscular contrac- 
tility has been found unimpaired in the earlier stages of the disease; but 
later it diminishes, the muscles continuing, however, to respond actively 
to galvanism after they have partly lost their power of responding to fara- 
dization. 

Electro-muscular sensibility has been found normal or imjiaircd in dif- 
ferent cases : in one of our patients i^ was diminished to faradization, hut 
remained acute to galvanism. 

The skin over the aflx'cted parts often presents a marbled or mottled 
appearance. In one ca.se that we have seen Ulescribcd by Mitclicll, /or*, n't.), 
the mottling ** consists of spaces of pallid t?kin surrounded by quite regular 
circles of congestion, which aflTect an irregular polygonal shape." The 
skin is usually thin and delicate, and can be easily lifted from the muscles. 
Disorrlers of the cutaneous sensibility have not been usually found, but 
Berger (ioc. cit.) describes violent neuralgic pains and formication, followed 
at a later stage by aniesihesia. We have already alluded to the pains in 
the limbs occa.-'ionally complained of in the early stages of the disease. 

The temperature of the part'* is lowered. This can be distinguished hy 
the hand, and has been found, on careful tlirrrnoinetric study, by Miichcll,* 



» Trans, of London Pai.i. >.. .. vol. xix, in , , ,. ,. 

» Wif-n. Med. Jahrb., 1872; and in .Syd. S«»c. Bicnn. Rfltronpocl, 1871-72, p. 71. 

* Deut. Arch. f. Klin. .Med., .March, 1872, Bd. ii ; Hfl. 4. 5, p. 303. 

* Thi^ case wr» re-examined by Gerhard {loc. eii , p. 31) nt a later periftd of itA 
d<»veIopment with the followint; r(?^ult«i : rmhl delU'id, \)2? ; left deltoid, 92}° ; right 
thigh (inner side), 94^" ; left thigh (inner »ide), 94|«» ; right calf, 1K)« ; left calf, WV*. 



632 PROGRESSIVE MUSCULAR SCLEROSIS. 

to be as follows: Left axilla, 97.5°; right axilla, 97°; perineum, 94.5°; 
right calf, 91.5° ; left calf, 91° ; and Estrazulas, in the case observed by 
him, reports the temperature in both axillse 98° ; on right calf, 91f ° ; and 
on left calf, 91°. 

The following case, which has already appeared in print {loc. eit), may 
be quoted as an illustration of many of the previous remarks : 

W. E., set. 20, was admittod to the Philadelphia Hospital, April 19, 1871. He 
was born in Virginia, and has resided there or in the District of Columbia until 
the present time. His parents are both dead, — his father from cholera, his mother 
from some unknown cause. He had two sisters and a brother, all of whom are 
dead, — two from unknown causes; but one sister had paralysis (apparcntl}' hemi- 
plegia) and was unable to walk for some time before her death. The patient him- 
self was a delicate and weakly child so far back as he can recollect. He never 
sutFrred either frcmi malaria or rheumatism. He was engaged in the country on a 
farm, and his strength was overta>ked by heavy lifting. He never, however, met 
with any injury. Six years ago he began to notice gradually increasing loss of 
strength in the legs, which progressed so slowly that for eighteen months he was 
still able to run about, though not so actively as other boys. He was not obliged 
to use a cane until two years ago, and since then only in walking considerable dis- 
tances. This gradually increasing debility was attended with no pain, formication, 
or subjective sense of change of temperature in the legs. There were also no con- 
tractions or cramps of the muscles. The progressive debility had not continued 
long before he noticed that it was necessary, when he was standing or walking, to 
throw iiis shoulders back and protrude his abdomen and lower part of the thorax, 
thus showing that the muscles of the back were affected at a very early date. Dur- 
ing this early period he could walk quite naturally, but in running he threw his 
shoulders far back and stretched his legs widely apart ; he assumed the same posi- 
tion also in going up an elevation. Two years later the muscles of the arms be- 
came affected in the same way as those of the legs and back. During the first three 
years he merely noticed that the legs did not grow as they should do, but afterwards 
atrophy began, first in the muscles of the calves, shortly after in those of the thighs 
and of the back, and soon afterwards in those of the shoulders and arms. About 
two years ago, after the atrophy of the muscles of the calves had become very 
marked, he noticed that they began to increase in size, and this growth has con- 
tinued until they have acquired a size much greater than they ever had previously. 
This process of renewed growth next appeared, about one year ago, in the muscles 
of the forearm, and has continued at a slow rate. During all this time his weak- 
ness has steadily increased; he has, however, never been kept in bed by it, but has 
been able to get about feebly by the aid of a cane. He has never had a sense of 
constriction about any part of the body. His appetite throughout has been good, 
his digestion fair, and bowels regular. His urine has always been passed with case, 
and has merely been noted to be occasionally yellow. About one year ago he was 
seized, without any apparent cause, with a severe epileptic convulsion, and since 
that time he has had similar attacks- at intervals of from fifteen to thirty days. He 
has usually been unable to tell when these fits were coming on, but occasionally he 
has had a strange feeling in the head, and has thought of foolish things, before the 
attacks. The fits have been attended with entire unconsciousness, sudden falling 
to the ground, and muscular convulsion. He has usually been half a day in en- 
tirely recovering from them. He has never had more than two convulsions on the 
same day. 

Present Condition. — His expression is natural, mind active, and special senses un- 
affected. The muscles of the face are not involved, and their action is perfect. His 
tongue is clean and moist, appetite fair, digestion easy, and bowels regular. There 
is no enlargement of the abdominal viscera. The urine is normal and secreted in 



I 



CASE. G33 

norniHl quantity. Hi* respiration? nro easy, twelve in the minute, chiefly dinphrnu:- 
niMlic: the ve>iouhtr murmur is soft and healthy. The cardiac sounds are normal. 
The pulse is To, in the recumbent position. 

Muscular System. — The muscles of the neck (sterno-eleido-mastoids and i-xtensors 
of the head) are of fair size, and their movements are strong and free. The Irapezii 
are fi*eble, and he retracts the shoulders with difficulty and feebly. The pectoral 
muscles are moderately wasted and feeble. The scapular group of muscles are less 
wasted and the scapulje do not project markedly from the thorax, so that the serrati 
magni are probably not much wasted and enfeebled. The deltoids are extremely 
wasted and he is unable to raise either arm within thirty degrees of the horizontal 
plane; when the arm is raised, there is a marked depression below the acromion 
process. The biceps muscles are also extremely wasted, and he is able to flex the 
forearm only a little beyond a right angle. The triceps muscles are also very 
feebb', and the lung head of eaeh is greatly wasted, while the external and short 
heads appear as quite prominent fleshy masses. 

The forearms seem unduly large in comparison with the atrophied arms, and 
are in reality largt*r than they have ever previously been. They have, moreover, 
H |M?culiar blunt and swollen appearance, owing to the sudden enlargment of the 
muscles above the wrists. The atrophy of the forearms seems never to have 
reached the degree attained elsewhere, so that the degree of consecutive bypt^rtro- 
phy has not been so m.-irkcd as in the calves. The grasp of tho hands is decidedly 
weaker than would be expected from the size of the forearms, that of the rijjht 
being much weaker than that of the left hand. There has been no atrophy of the 
muscles of the hands. 

"When he sits up in bed, he is only able to hold the shoulders back with effort; 
there is increased bowing forward of the vertebral column, with absence of the 
lumbar d<'pression. There is decided wasting of the erector spinse muscles on 
eiihrr side. When lying in bed, the lumbar spine is raised, so that the obliquity 
of the pelvis and hypogastric region is increased. The muscles of the abdomen and 
thorax are not wasted, and preserve goi>d strength. 

"When he is lying down, the feet are strongly extended and adductod (equino- 
varus}, so that the toes point t<»wards each other, while the soles rest on the bed. 
There is great prominence of the tarsus. The muscles of the thighs are all much 
wa>t**d, a.< are those of the buttocks. It is with difficulty that, when lying down, 
he can draw up the l«'g> by the action of the flexor muscles. He has much m«)rc 
power of extending them by the quadriceps extensors. The rotators, abduct<»rs, and 
adductors of the thighs are much less affV-cted. He can move in bed only by a 
wrigg'iing motion. 

The calves a[)[»ear as large as those of a vigorous man, contrasting very strangely 
with the waited thighs. They feel quite firm, even when relaxed, and when he 
contracts the muscles they stand out well, and are hard and clastic. The heads of 
the tjastrocnemii especially become prominent, standing out lik<' firm subcutaneous 
tumors. He has considerable power of flexinir, adducting, and alMlucting the feet, 
but the extensors are very feeble The muscles of the right thigh and leg are de- 
cidedly stronger than the i-orre«ponding ones of the left i*ide. 

In rising from the recumbent position into a sitting one, he is obliged to mako a 
very strong cffi»rt. When about to stand up, he throws his body forward till it aU 
mr»*t rests on his thighs, and then, placing his hands on his knees and rising a little 
from his sext, he ^lowly raises his body by sliding his hands U[» his thighs; and 
when h*» has raised him.«flf as far as po'siblo in this way, he places one hand after 
thr- olhor on a chair-bnck or edge of a table, and b-anti forward. He then, by jorks 
of the alternate sides of the body, draws his legs forward, thus assuming more and 
more nearly an erect position. So soon a.* he approaches this, the legs are widely 
separatr-d, the shoulders thrown quickly back, and the abdomen protruded, and, 
«U»T tottering a few times, he secure* his r>quilibnum in this peculiar position. It 
U very tiresome for bim to stand without some support, and when bo does to b« 



634 PROGRESSIVE MUSCULAR SCLEROSIS. 

bears with his whole weight on the right foot, the sole ^of which rests flat on the 
ground, while the left leg is thrown forward in advance, and the heel elevated 
from the ground. When a support is afforded him, he places both hands on it, 
and leans forward, rising on the balls of the feet, so that the heels are raised one- 
half inch from the ground. In this position he stands for half an hour or more 
at a time. The muscles of the calves are contracted and thrown into prominent 
relief. 

In walking, as in standing, the shoulders are thrown very far back, and the lum- 
bar depression is rendered very deep ; the arms hang down by the sides, coming 
decidedly behind the line of the buttocks. The legs are kept quite widely apart. 
He advances each one b}' resting his weight on the opposite foot, and then swing- 
ing forward the whole side, the foot describing a slight arc. At the moment of 
thus swinging forward either leg, he rises slightly on the opposite foot. While 
standing on the right foot, the whole sole rests on the ground, though the heel 
merely touches it lightly; but when his weight is thrown entirely on the left leg, 
the left heel still does not touch the ground. The effort of advancing each leg is 
evidently great ; the muscles of the thighs tremble and quiver, but those of the 
calves contract forcibly and are thrown into bold relief. Walking is very tire- 
some, and gives him pain and soreness in the back. No fibrillar contractions are 
seen in any of the muscles. 

Elective examination^ April 23d, 1871. — The muscles of the forearm (tested on the 
right side) contract well under a faradic current of rather unusual strength ; they 
also respond well to faradization of the brachial plexus. Electro-muscular sensi- 
bility is not acute, though this may be a mere individual peculiarity. The muscles 
of the arm, the pectoralis major, and the trapezius all contract on faradization, 
whether direct or applied to their motor points. It requires rather too powerful a 
current to produce these effects. A still more powerful current is required to induce 
contraction of the thigh muscles, but they all respond, though feebly : the sensibility 
to the current is impaired. The contractions of the flexors of the leg on the thigh 
are the most feeble, and are obtained only by very strong currents. The muscles of 
the leg respond more actively than the muscles of the thigh, whether the electrode 
is placed over the nerve in the thigh, or on the motor point of the muscle, or di- 
rectly over its body. 

When tested with a galvanic current, the muscles of the calves of the legs con- 
tract with each interruption and renewal of a current of rather unusual strength 
(twenty cells, Stohrer), and electro-muscular sensibility is acute. The muscles of 
the thighs also respond, but with more diflSculty, to the galvanic current. 

The following measurements were taken : 

Eight arm, greatest circumference, 7 inches. * 

" forearm, circumference one inch above wrist, 6 '' 

" " " at middle, 8^^ " 

" " " three inches below elbow, point of greatest thickness, . ?>% " 

" thigh, circumference hand's breadth above knee, 10|4 " 

" " " at middle, 113^ " 

" " " close to perineum, 12% " 

" calf, " at thickest part, 1*2 J^ " 

Left arm, corresponding point, 7 " 

" forearm, " " 6 " 

" " " " 83^ " 

" " " " 8% " 

" thigh, " " 103^ " 

" " " " 11% " 

" " " " 12^ " 

" calf, " " 1%^ " 

The general sensibility is everywhere normal, and there are no subjective dis- 
turbances of sensation. The circulation of the extremities is somewhat feeble, and 



CASE. 635 

both hand? and feet rendily become bluish on exposure to c6ld. The color of the 
surfrtce is. however, everywhere norninl, without any ni(»ttling. 

April 30. — He hnd to-day an epileptic attack, with frothin*::^ at the mouth, iren- 
eral muscular spasms, and unconsciousness, lastinj; for eii;ht minutes. There was 
deep stupor and sleep for four hours subsequently, and he did not entirely recover 
until the followini; morning. The fit was preceded for about a minute by the fool- 
ish fancies he has fri-quently had before. 

OrderiKl s\ r. phosphat. comp., f*5ij, t. d Faradization of arms and lo^s on alter- 
nate days. 

A fraijment removed by Duchenne's " emporte-piece " from the left deltoid was 
of a slightly pale reddi'sh color. When exanjined microscopically, a large niiijor- 
ity of the fibrils showed distinct, though often fine and delicate, transverse striation. 
In a few instances, striation was entirely absent, the fibrils looking homogeneous 
and much like ground glass cylinders. In a very few fibrils, also, distinct longi- 
tudinal striation was visible, and in others there was multiplication of the nuclei 
in the .«arcolemma. In not a single fibril was there any trace of fatty degenera- 
tion. The fibrils varied in size from jl^^^ to ij^^g'', or even, in a few cases, yj^''. 
The striation wjv« particularly faint, or at times even absent, in the largest fibrils. 
There was a lari^e amount of interstitial white fibrous tissue, with abundant gran- 
ular matter containing many oval nuclei. In places there were small collections, 
of minute fat-globuleS or refracting granules. 

Fragments removed from the gastrocnemii presented closely analogous condi- 
tions. The muscular tissue was merely rather paler red than normal. The mus- 
cular fibrils varied greatly in apjioarance and in size. The transverse striation was 
in some fibrils perfectly healthy, but in a majority it was altered, though in various 
ways. Thus, in some it was very faint and difficult to distinguish ; in others, it 
was whidly absent, the fibrils presenting the appearance of fine ground-glass. In 
other fibrils there was a marked appearance of longitudinal striation, due to deli- 
cate fibres or verj' fine fusiform cells arranged in the long axis of the mu cular 
fibril. In many fibrils there was distinct excess of the nuclei of sarcolemma, 
which Hj»peared as large oval nuclei with a punctiform nucleus. A few fibrils 
presented streaks of minute fatty granules along their centres, and a very small 
nuuiber were decidedly fntty. The muscular fibrils varied greatly in size also. 
Many were about tss'' to 5J5" in diameter; but a number were ^^5" to jIj^^^, 
while others were as much as yjj", yiff'^i 205'' '" width. There was a large ex- 
cess of interstitial tissue, in places taking the form of long, narrow, wavy bands 
of pure white fibrous tissue; in others, appearing as abundant granular stroma, 
thi'.kly strewn with ovhI nuclei. There wa-s also some curly, elastic fibrous tissue. 
There was a considerable amount of interstitial, fat, existing as scattered globules, 
or arranged in patches of large, closely aggregated fat-globules. In places, iso- 
lated muscular fibril.* lay imb^'dded in this fibroid tissue so as to be scarcely visible ; 
but in other places a number of fibrils lay directly in contact with each other, 
forming a little bundle, around which the excessive growth of interstitial ti-^sue 
had occurred. The arterioles and capillaries appeared healthy. No nerve-fibrils 
were detected. 

The patient continued for several months upon the above treatment, and appeared 
to gain slightly in strength. The recurrence of his convulsions was checked by full 
dose* of bromide of potassium ; still it could not be said that any material improve- 
ment had occurred, when he left the hospital, and was lost sicht of. 

There i.*« u.sually an entire want of (li.«<turhance of the gononil hoalth. 
The apf^Kftite remains goorl until a late jMiriod, dige?»tion is well fwrforined, 
and the action of the bowel.*? i.** regular. Neither the rectum nor the uri- 
nary bladder becomes paralyzed. There is frequently an entire want of 
cerebral symptoms, and the mind may be clear until the close of the case. 



636 PROGRESSIVE MUSCULAR SCLEROSIS. 

In several instances, however, the patients have been of feeble intelligence, 
or even idiotic ; and in the case above reported, it will be remembered that 
the disease was complicated with epileptiform convulsions. 

Course and Duration. — As will be inferred from the foregoing de- 
scription, the duration of this disease is very considerable, varying from 
five to fifteen years, or even more. It may occupy several years in reach- 
ing its full development, and may then remain at this stage for several 
years, or even until a tolerably advanced period of youth, but finally it 
is succeeded by a stage in which the loss of power becomes more com- 
plete and extensive, involving the upper extremities and muscles of res- 
piration, and confining the patients to the recumbent position. During 
this final stage there is a rapid decrease in the size of the hypertrophied 
muscles, and the limbs may even come to present an appearance of great 
atrophy. 

Death usually occurs before adult age from sheer prostration or from 
some intercurrent affection of the respiratory organs. 

Prognosis. — The course of this disease is steadily progressive, and, 
despite the various plans of treatment adopted, usually leads to a fatal 
result. In one case, however, recovery took place, and in one other there 
was some improvement. In the case we have here reported, there seemed 
to be some temporary improvement under treatment. 

Diagnosis. — The diseases from which it is most important to distinguish 
progressive muscular sclerosis are atrophic infantile paralysis and progres- 
sive muscular atrophy. In infantile paralysis, however, the suddenness of 
attack, frequently associated with fever or with some cerebral disturbance, 
as convulsions ; the occurrence of complete and more or less extensive 
paralysis ; the gradual disappearance of the paralysis in some parts, while 
in others it remains permanent; the diminution and ultimate loss of electro- 
muscular contractility ; the occurrence at a later period of fatty degenera- 
tion and atrophy of the affected muscles, with arrest in the development 
of the bones and marked deformities ; and the entire absence of any sec- 
ondary enlargement of the parts involved, constitute a series of distinctive 
features so clear and decisive as to render the differential diagnosis easy 
and certain. 

A disease from which it is much more important to carefully distinguish 
progressive sclerosis of the muscles is progressive muscular atrophy occur- 
ring in childhood. The especial importance of the relations of these two 
diseases depends on the fact that both are alike diseases of nutrition of the 
muscles, thus constituting a group quite distinct from all the forms of true 
paralysis. In both the disease begins — usually without any apparent 
cause — insidiously, and progresses slowly but surely. In both the loss of 
motor power is secondary to the changes in the muscular tissue ; in both 
the muscular degeneration and consequent loss of power almost invariably 
progress steadily to a fatal result. These two diseases, then, stand related 
to each as being alike caused by disturbance of the trophic nervous system, 
but they are at the same time most positively separated from each other 
by marked differences in their course and symptoms. 

Thus, in progressive muscular atrophy, the disease nearly always begins 



II 



4 



MORBID ANATOMY AND NATURE. 637 

in the upper extremities, and invades subsequently the trunk and lower 
extremities. Indeed, Duehenne has pointed out that when this disease 
appears in ehihlhood, which is quite rare, it usually begins in the iaee, 
where it produces atrophy of" the orbicularis oris and the zygomatici, and 
does not extend to the trunk and extremities until after a period varying 
from two to three vears. It then follows the same descendinjr course seen 
in cases occurring in adults. The atrophy usually afiects the muscles 
irregularly, so that various deformities and vicious positions of the parts 
involved are developed. Microscopic examination shows a progressive fatty 
degeneration and atrophy of the muscular fibrils, and in proportion as this 
increases there is loss of power and of electro-muscular contractility. One 
further symptom of high diagnostic value is the frequent occurrence of 
fibrillar contractions in the affected muscles, which, although stated by 
Berger to be of constant occurrence in progressive muscular sclerosis, has 
not been found so by ourselves or other observers. Finally, the muscles 
which have progressively atrophied never undergo any secondary enlarge- 
ment, nor does microscopic examination reveal any lesion of the interfi- 
brillar connective tissue. In all these particulars, then, progressive mus- 
cular atrophy differs widely from progressive muscular sclerosis, which is 
almost exclusively a disease of childhood, beginning in the muscles of the 
lower extremities and advancing upwards, producing a peculiar mode of 
standing and walking, and in which the affected muscles, with or without 
a previous stage of atrophy, undergo remarkable enlargement, usually 
without fibrillar contractions, and with preservation of electro-muscular 
contractility till a comparatively late period of the disease. The results 
of microscopic examination, also, as detailed in the next paragraph on the 
morbid anatomy, are entirely diflferent from those observed in progressive 
atrophy. 

Morbid Anatomy and Xatuije. — There is still an urgent need of care- 
ful, skilfully conducted microscopic examinations of the nerve centres in 
this disease. The examinations which have been made up to the present 
have not yielded uniform results. In two of them, Cohnheim's (when how- 
ever the microscopic study wa.s not conducted with the requisite care and 
thoroughness) and Charcot's,' no lesions were found in the spinal cord ; 
while in the cases reported by Miiller,' Barth,'and Lockhart Clarke,* posi- 
tive lesions of the cord were discovered, chiefly affecting the anterior col- 
umns of gray matter and the large nerve-cells which exist there. J'ulen- 
burg had already suggested that the pathological origin of this affection 
would he found in some defective formation or di.scase of these partes ; and 
in the fir.rt publication made on this subject by one of ourselves, when 
Cohnbeim'a imperfectly studied ease wa.s the only one on record, we stated 

' Sur Tetnt anatomique fl«» inui«clej» et dc la moelle ^pinidre dans un caH do paraly- 
sie p»eudo-hyperirophiqup, Arch, de Phy». March, 1872, p. 228. 

» Beitrage z. Path. Anal. u. Phys. d. men»chlichcn Ruckcnmarkfi, lift ii, L»'ip- 
zig, 1H70. 

' Beitrage z. Kenntniss d atrophia mufculorum lipomato^a; Arch. d. Hcilkund., 
Leipziir. 1871. p. 120. 

* Mcdico-Chir. Trans., vol. xWii, 1876, p. 247. 



638 PROGRESSIVE MUSCULAR SCLEROSIS. 

that analogy with other diseases of the nutrition of the muscles supported 
this suggestion. Hammond {pp. cit, p. 500), " feels warranted in at least 
provisionally accepting the view, that the anterior tract of gray matter 
is the seat of lesion in pseudo-hypertrophic paralysis." Ciiarcot, on the 
other hand, contends that the anatomical cause of this affection is not seated 
in the spinal cord. Berger {loc. cit) assumes the existence of trophic 
nerves, and attributes the disease to some disturbance of their function. 
Duchenne, on the other hand, ascribed it to a paralysis of the vaso-motor 
nerves; and others again regard it as a primitive muscular lesion. It is 
evident, therefore, further careful examinations of the spinal cord in this 
disease are necessary before a definite conclusion can be reached on this 
point of vital importance. 

The condition of the affected muscles themselves has been very carefully 
studied during life, on small fragments removed by Duchenne's trocar^ 
(emporte-piece), and the results confirmed by examination after death. 

When examined by the naked eye, their color is altered, and the mus- 
cles present either a uniform pale or yellowish appearance, or are marked 
with stripes of yellow or yellowish-white ; on section they shine with a 
dull, greasy lustre. 

The results of microscopic examinations vary somewhat at different 
periods of the disease. The changes affect both the muscular fibrils, and 
even more markedly, the interfibrillar connective tissue. 

In the early stage, Berger asserts {loc. cit) that he found in two cases an 
absence of change in the interstitial tissue, and a marked hypertrophy of 
the fibrils themselves. This enlargement has not, however, been constantly 
observed. The fact of its occurrence, and of its persistence in some fibrils 
even in a comparatively advanced period of the disease, is confirmed by 
the observation of Ley den, ^ Estrazulas {loc. cit), Knoll {loc. cit), and our- 
selves. In the later stages, many of the fibrils are pale and small, being 
occasionally reduced, according to Cohnheim, to -|th their normal diameter ; 
in some places empty sheaths of sarcolemma are seen. Many of these 
fibrils, though altered in size, present no other morbid condition, either 
fatty or granular. Knoll observed in some of the border fibres a tendency 
to split into two ; and Martini^ describes a peculiar process of fission or 
division of some of the atrophied fibres. In the cases recorded by Meryon 
{loc, cit), which were probably of this form of disease, a granular degener- 
ation of the muscular fibres, with rupture of the sarcolemma was observed. 

The most marked change is, however, in the condition of the interstitial 
tissue. It is not known definitely whether this precedes all change in the 

1 This useful little instrument is shaped like a trocar. The blade is, however, a 
hollow cylinder, composed of two parts, one of which, bearing the point, is fixed, 
while the other can be withdrawn a little by sliding a movable button on the 
handle. The trocar is introduced closed into the substance of the muscle, the but- 
ton withdrawn, so as to open the cylinder and allow a fragment of muscle to pro- 
ject into it ; the button is then pushed forward, cutting off and securing the little 
morsel of tissue. 

2 Berl. Klin. Wchnschr., 18G6. 

3 Centralblatt, 1871, 641; in Syd. Soc. Bienn. Ketrospect, 1871-72, p 70. 



NIGHT TERRORS. 639 

rauscular fibrils themselves. But at least by the time that eiilarj::ement 
of the muscular masses can readily be detected, there is usually, despite 
the two observations of Berger, marked proliferation of its nuclei and 
hyperplasia of the fibrils. This continues to increase until at places the 
muscular fibres are sepanited by broad tracts oi' wavy fibrous tissue, in- 
tersj^rsed with fine nuclei. At a later period this is associated with in- 
creasing interstitial fatty accumulation and degeneration, which advances 
with varying rapidity, even leading in some cases to such extreme accumu- 
lation of fat as to be visible to the unaided eye as yellowish streaks. It 
is probable that the rauscular fibres may temporarily share the exagger- 
ated nutrition of the surrounding connective tissue, but later, as this inter- 
stitial tissue accumulates, the fibrils are subjected to severe pressure, and 
undergo atrophy in many instances. The entire process, therefore, seems 
to be of a strictly sclerotic character, so far as the interfibrillar connective 
tissue is concerned, but associated with an irregular and as yet undeter- 
mined stage of true hypertrophy of the muscular fibrils themselves. 

Treatment. — The results of treatment in progressive muscular sclerosis 
have so far been highly unsatisfactory. The internal remedies from which 
most benefit may be expected are those which tend to improve nutrition, 
and especially to improve the tone of nutrition of the nerve-centres. 
Among these, cod-liver oil, iron, the compound syrup of the phosphates, 
and arsenic, may be specially mentioned. In the case reported by our- 
selves, where there was the complication of epileptiform convulsions, bene- 
fit was derived from a course of bromide of potassium. 

The remedy, however, from which most good is to be expected, is elec- 
tricity. This has been used by Duchenne with great benefit, in the form 
of faradization of the affected muscles. It is asserted by Benedikt, that 
good results have been attained in three cases by the use of the direct cur- 
rent, the copper pole being placed over the lower cervical ganglion, and 
the zinc pole along the side of tiie lumbar vertebrie, by means of a broad 
metal plate. Others have, however, tried this mode of treatment for a 
long time without any success. As, however, no more plausible mode of 
treatment has yet been suggested, we should be inclined to adopt it in 
conjunction with direct faradization of the affected muscles, and the use of 
the internal remedies above recommended. 



ARTICLE XIV 

KIGHT TERKOIW. 

The night terror of children i» a condition, in some regpectp, analogous 
to the nightmare of the adult. It is not quite the ««me, howev«r, for in 
nightmare the subject is relievefl of the pymptoms w) soon a,'* he awakes 
from the sleep in whjch the dream has occurred, while in night terror the 



G40 NIGHT TERRORS. 

symptoms coiitinue for some time after the patient has been roused suffi- 
ciently, to utter cries, and to exhibit in the expression of the countenance, 
and in the movements, an accordance with the painful idea which occupies 
the mind. It is perhaps, more akin to somnambulism than nightmare. 
But we will cite some of the cases w^e have met with, and then endeavor 
to explain the pathology of the condition, and to describe its proper treat- 
ment. 

Several years since, one of us had the charge of a family of five children, 
all of whom were more than usually intelligent, and all were liable in early 
childhood to frequent attacks of night terror. One of these children died 
early of serous eff'usion into the ventricles of the brain, occurring after a 
severe attack of diarrhoea. The eldest child, a son, who became quite a 
distinguished student and lawyer, was specially liable to this condition. 
He would wake partially from sound sleep, screaming, struggling, and ex- 
hibiting all the signs of a violent terror. This condition lasted for several 
minutes after the screams and struggles had begun, during which time it 
was evident that he was under the influence of some terrifying idea. The 
only thing to be done at the time was to hold him gently in the arms, and 
endeavor to rouse him into full wakefulness by soothing words and caresses. 
During his early years he was unable to explain the character of the idea 
which caused the distress. At a later period he recollected that the ter- 
rifying thought was always one connected with some object of vast size. 
Many of the attacks, he said, arose from his seeing in his sleep an elephant 
in the nursery, which, from being small in size at first, expanded before his 
eyes to such a size that he was being crushed between it and the walls. 

In another case, we were sent for to see a young child, one of a large 
familv, of nervous and rather timid type, which, whilst playing on the 
floor of the nursery one morning, was bitten in the foot by a tame parrot 
as it hopped about the room. The child, though' not seriously bitten, was 
very much alarmed at the time. On the following night, at midnight, it 
started suddenly from a sound sleep, shrieking, " Take the parrot away, 
take the parrot away," and was so alarmed and terrified, and struggled so 
violently and so long with the idea, that the mother, a very sensible and 
experienced person, became quite alarmed lest it should have a convulsion, 
and was on the point of sending for us. At last, by carrying it about and 
soothing it gently, it was fully waked and the terror passed away for the 
time. This scene was repeated for several nights afterwards at about the 
same hour, but with diminishing violence, until the impression faded away 
and disappeared. At the time of the occurrence the child was perfectly 
well, and when we visited it on the following day and for several days 
afterwards, there was no disturbance of the health requiring medical 
interference. The attacks were evidently the result of the vivid impres- 
sion made upon the child in the daytime, which, by the play of memory 
during sleep, reproduced to the child all the pain and terror endured at 
the moment of the occurrence. 

We were sent for on another occasion to see a little girl of six years of 
age, who had alarmed the mother greatly during the previous night by 
partially waking from sound sleep, screaming, " Take the white dog away, 



CASES. tUl 

oh, take the white dog away !" with such terror in the countenance and 
eye, surh agitation and struggling of the limbs, that the mother feared it 
niuj't have a fit. It was many moment:? before it could be roused suffi- 
ciently from the delirious terror to recognize those around it, and to know 
that there wa:* no dog by its side. The terror was repeated for several 
Dight^ at about the same time, and then gradually passed away. In this 
case, the child had l>een walking in the street with the mother, on the day 
before the first dream occurred, and had been suddenly shocked and ter- 
rified by a large white dog brushing sharply against her, as it was careering 
along the street. There was no disturbance of the health at the time nor 
afterwards. As in the last case, the attack was evidently the result of the 
reproduction in a dream of the fright it had had in the street. 

The following case was still more curious. It is related very much in 
the language of the mother. The child, a girl two years and two months 
old, wa.< the daughter of a very bright and highly educated mother, and of 
a father of unusual intelligence and force of character. The child was 
herself very precocious and active-minded. The parents were both very 
healthy persons. On the night of Sept. 13th, 1873, the child awoke par- 
tially in a great fright, screaming, trembling, and covered with cold 
perspiration. Nothing calmed her for some time. She repeated over and 
over again, " Teeth bite you, teeth bite you." Finally, at the end of an 
hour, she was roused from the state of half sleep, the sobs and crying 
cea.«H?d and the attack ended, but at dawn of the same night there was 
another seizure which was not quite so violent. During the attack she 
l>egg<'d to have her head covered, evidently fancying that this protected 
her from some threatening object. During the following day she mani- 
fested great fear of the large slop jar in the nursery, and could not be in- 
duced to approach it. When her father took it into his hands to explain 
to her that it was "only ajar," she screamed most pitifully and seemed in 
abject terror. Being a child of peciHiarly vivid imagination, it was 
supposed that she had, by some freak of fancy, come to imagine the top 
or opening of the jar, to be an open mouth armed with teeth, ready to 
rend and tear her. She conceived, also, a great terror of the carved orna- 
ments on the head-lxjard of her crib, and, indeed, these fears became so 
marked and so great, that she was moved into another room, where the 
fin.:*'ire was plainer and unvarnished, so that the shadows and reflections 
_ not feed her disturbed fancy. In December she was seized with 
typhoid fever, from which f*he did not recover until February, 1874. In 
that month her mother had another child, a boy. When she was taken 
into the chamber to see her little brother, she had another nervous attack, 
in w},i. li she fancieii that an animal wa.'i biting her mother and that it 
rnii.'lit i>ite her al^). The nervous seizures at night continued to recur at 
intervals of about five weeks, generally after violent exercise or hearty 
f^*''ir..r, until May, 1875, when a severe attack of scarlet fever seemed to 
ite them in great measure. At the present time, she has a night 
terror only when her imagination has been, in some way, excited, or her 
i^ympathies overtaxed. 

With one more case, which shows the curious features of this sleep-in- 

41 



642 NIGHT TERRORS. 

toxication in a very marked manaer, we shall end the citation of cases, 
and pass on to a consideration of the pathology and treatment of the 
condition. 

A gentleman, whose eldest son was rather remarkable for his intellectual 
development, was roused from a sound sleep in th« early morning by a 
touch on the shoulder. On waking he saw this boy, then about twelve 
years old, standing by the bedside, dressed in his wrapper, his legs bare, 
and with his bare feet in slippers. The boy said : " Father, there are rob- 
bers in the house, they are downstairs now, but I do not think there is any 
danger, for I have been downstairs and have locked the doors, but I thought 
I had best tell you." The father thus waked suddenly from sleep, thought 
at first that the child was insane, but seeing some peculiar fixity in his look 
and manner, it flashed into his mind that the child was acting under the 
influence of a dream. He touched him sharply, and said loudly, " My 
son, you are sleeping ; wake up, wake up." The boy drew a long, deep 
breath, gaped, waked, and said, " Why, so I am," and walked off to bed 
again in the most natural manner. 

Pathology. — The best explanation of the conditions which exist in this 
curious disorder of sleep is, we think, to be found in the works of writers 
on forensic medicine. Thus, Dr. Johann L. Caspar {Forensic Medicine, 
Sycl. Soc. Ed., vol. iv, p. 273), remarks that " the dreaming state passes 
quite insensibly into that of somnolence, that middle state betwixt sleeping 
and waking, in which the connection with the outer world is neither that 
of sleep nor waking. The dreaming state is wholly sleep, somnolence is 
half sleep, half waking. In it the senses are neither quite awake nor quite 
roused, but are surrounded by a cloud of dream phantasms ; the somnolent 
man sees and hears self-made phantoms instead of real objects ; he hears a 
shot fired, and dreams of it, while it was only a stool that fell. He reasons 
logically, as is well known to be the case also in dreams, in regard to the 
impressions supposed to be felt, ahd may, since muscular action is not pre- 
vented by sleep, act in the most illegal manner." 

In the Treatise on Medical Jurisprudence (Philadelphia, 1855, p. 119), 
by Wharton and Moreton Stille, in the article on " Mental Unsoundness 
as connected with Sleep," it is stated that " under this general head may 
be grouped somnolentia or sleep drunkenness, somnambulism, and night- 
mare, the two last of which may be joined." Sleep is interrupted, they 
suppose, by whatever terminates the peculiar condition of the brain upon 
which sleep depends, by the natural exhaustion of the state of the brain, 
by vivid and sudden impressions on the senses, and by disagreeable sensa- 
tions. " Now, in a certain morbid condition of the brain this awakening 
is not complete, and does not restore the waking state with a full and cor- 
rect perception of surrounding things, but an intermediate state between 
sleeping and waking is produced, which resembles intoxication, and is 
called the intoxication of sleep (schlaftrunkenheit). This state admits of 
action, which is directed by the phantoms of the dream ; talking in sleep 
being very nearly allied to waking, and dreams themselves being midway 
between sleeping and waking, for in the depths of sleep we no longer be- 
come conscious of dreams." In this explanation they differ somewhat 



I 



CAUSES — TREATMENT. 643 

from Caspar, who a?sert5 that dreams are "purely phantasmagoric concep- 
tions arising spontaneously in the brain, which continues to act during sleep 
and during the so-called dreamy waking, without any stimulation produced 
by the external world through the senses." Wharton and Stills say further: 
" It is important to dfj^tinguish somnolentia, or sleep-drunkenness, which is 
a state which in a greater or less extent is incidental to every individual, 
from somnambulism, which is an abnormal condition incident to very few." 
The experience of every-day life demonstrates how much the former enters 
into almost every relation. Children, particularly, sometimes struggle con- 
vulsively in the effi^'t to wake up, which often is continued for several min- 
utes. The very exclamations, " wake up," " come to," which are so common 
in addressing persons in the waking condition, are scarcely necessary in 
bringing to the mind many recollections of cases where the waking struggles 
were peculiarly protracted. Of course there are constitutions where this 
struggle is peculiarly distressing, just as there are constitutions in which 
the tendency to sleepless^ness is equally marked. If we recall to the reader 
the fact, that it is in the state of somnolentia or sleep-drunkenness, that acts 
of violence have been committed by persons, as stabbing a friend, shooting 
a passer-by who sought to wake a sleeping sentinel, and other acts of this 
kind, for which the unfortunate individual has been tried for his life, all 
of which unhappy events have been committed in the mental state induced 
by some dream, which has pursued the patient into the only partial awaken- 
ing, it will not be difficult to understand the phenomena we have described 
as occurring in some of the cases of night terrors above cited. 

Causes. — In some children it evidently needs but a vivid impression 
upon the mind in the waking state, to produce in the course of the fol- 
lowing night, and sometimes for many nights afterwards, the dream which 
is to cause all the phenomena of the severest night terror. The child 
may be in perfect health, and yet the mind shall, in sleep, so act as to re- 
pro<luce in full or in exaggerated force, the terrors which have been first 
felt in the waking state, and perhaps whilst the child was in full, happy 
play. Such were the cases in which the child had been bitten by a parrot 
whilst playing ou the floor, and that in which it had been shocked and 
terrified, whilst walking the streets, by the large dog brushing against its 
perp<^»n. In other case?, children predisposed to this condition by some un- 
usual activity of the brain, have the attacks whenever their health is de- 
ranged in any way, aa by indigestion, or by febrile disturbances from any 
cause. We have met with the attacks often in the various greater or lesser 
perturbatioM of health which accompany the different diseases of child- 
hood. 

Treatment. — The only treatment necessary during the attack is for the 
mother or nuree to take the child into her arms, and endeavor by gentle 
and soothing means to wake it fully from its half sleep. Gentle move- 
ments, care<wes, soft words, stroking the head and limbs, indeed, the very 
conduct which any tender mother would naturally adopt towards a terrified 
and frightened child, are the proper means to be used in the paroxysm. 

If, at the time the child is having these attacks, there is any faidt in 
the health, this should be attended to. The digestive system especially 



644 NIGHT TERRORS. 

ought to be carefully examined ; constipation should be relieved ; the diet 
ought to be arranged with great care, so that it may be readily digested, 
and yet be abundantly nutritive. If the patient is pale, iron ought always 
to be given for some weeks. If there be any trace of periodic disturbance 
from latent or open malarial disorders, quinia is of the utmost use and im- 
portance. When the attacks recur night after night, we know nothing so 
useful as the bromide of potassium or sodium, of which from two and a 
half to five grains may be given at bedtime for one or more weeks. It is 
often wise, particularly when the disturbance is of obstinate continuance, 
to add from one to two or three minims, according to the age, of deodorized 
laudanum, to the dose of bromide. 



\ 



I 



CLASS V. 

GENERAL DISEASES. 

INTRODUCTORY REMARKS. 

This great class includes a large number of diseases, both acute and 
chronic, in which the system at large, including the blood, is affected by 
the morbid process. For the sake of greater clearness and convenience, 
the chronic diseases of this class which appear to us to call for a special 
discussion in the present work, will be treated subsequently in a separate 
class, termed " Cachectic Diseases." The acute general diseases may 
further be subdivided into those which are diathetic, as rheumatism, and 
those which are zymotic, or dependent upon the action of some infectious 
principle introduced from without into the system. 

The zymotic diseases include some which are unattended with eruption, 
as mumps, diphtheria, and malaria, as well as the great class of eruptive 
fevers. 



ARTICLE I. 

ACUTE RHEUMATISM. • 

As it is not designed to enter into a full discussion of the numerous 
affections which merely occur in childhood in common with the other 
perifxls of life, we shall present but a brief account of rheumatism in 
children, alluding particularly to those points in which it differs from the 
same disease in adults. 

The importance of this subject is, we believe, not usually appreciated ; 
and it is not treated of at all in many of the treatises on diseases of chil- 
dren. Rheumatism in children deserves careful consideration, however, 
not only on account of its frequency and peculiarities, but also on account 
of its marked tendency to cardiac complications, and of its recently estab- 
lished relation to chorea. This question has been treated of under the 
head of the latter affection, and We will limit ourselves at this place to the 
discussion of acute articular rheumatism. 

Symptoms. — Acute rheumatism expresses itself in the child, as in the 
adult, by painful inflammation of one or more of the larger joints, usually 
accompanied by a high grade of febrile action. It is probable, however, 



646 ACUTE RHEUMATISM. 

that in the majority of cases in children, the fever is not so intense nor the 
course of the disease so long, as in adults. 

The fever, which is one of the most marked symptoms, may precede 
the development of inflammation of the joints by one or two days, or may 
coincide with the appearance of pain and swelling. It is generally marked 
in severe cases, and attended by frequency of the pulse, great heat of the 
skin, and, usually, copious acid perspirations. The heat of the skin and 
frequency of the pulse constitute a good index of the severity of the dis- 
ease, and we may always apprehend a dangerous attack when the tem- 
perature rises above 104° or 105°. 

With this febrile action, we find disturbances of the digestive functions ; 
the tongue is heavily coated, the appetite lost, or nausea may be present, 
and the bowels are sluggish, the evacuations being dark and offensive. 

The local phenomena attending this fever depend upon acute inflamma- 
tion of some of the large joints. 

Occasionally the ankles, knee-joints, wrists, elbows, and shoulder-joints 
will be simultaneously affected ; but in far the majority of cases, a few 
only of these articulations will be involved, and the others become affected 
subsequently, if indeed they do not escape entirely. But one of the most 
characteristic features of this specific rheumatic inflammation, though 
most marked in the chronic form, is its tendency to shift its seat, and we 
may fiud the intense pain and heat of one part transferred within twenty- 
four hours to a distant joint. We can rarely learn from the little patients 
the character of the pain which causes such bitter complaints; in one mild 
case, recorded by Rilliet and Barthez, it was compared to frequent light 
blows given upon the affected joints. 

The heat of the inflamed part is always much increased, and it is not 
unusual to find its temperature ranging from 100° to 105° (Aitken). 

The swelling is generally considerable, so that the shape of the parts 
may be much changed. When the knee-joint is inflamed, the effiision may 
raise the patella from its position on the condyles. 

The skin over the inflamed joints usually presents a more or less decided 
blush. 

We must not, however, overlook the fact that the severity of these 
articular troubles is not always commensurate with the rheumatic fever, 
and that frequently, especially in very young children, the local signs may 
be slight or even absent, and the only feature which tends to reveal the 
real nature of the disorder may be soreness, evinced by cries on every 
attempt to move the patient. 

Duration. — The duration of acute rheumatism varies exceedingly. 
According to Rilliet and Barthez, it follows a much more rapid course in 
children than in adults, occasionally yielding at the end of six days, and 
nearly always before the fifteenth day. We have, however, seen the rheu- 
matic fever last twenty-one days, and before convalescence was fully 
entered upon, six weeks had elapsed. 

There is a marked tendency to relapses and second attacks in rheu- 
matism, at whatever age it occurs; and we frequently meet with children 



CAUSES — PROGNOSIS — DIAGNOSIS. 647 

of twelve or fifteen years of age who have passed through three or four 
acute attacks of this disease. 

Causes. — Age. — Early infancy appears to protect, to a certain extent, 
against this atiection. Rilliet and Barthez allude to a case occurring at 
the age of seven months ; but the earliest age at which they met with it 
was at four years in a single case. We have ourselves met with it, al- 
though in an imperfectly developed form, in a number of cases in young 
children ; and are satisfied that the nature of these attacks is often over- 
looked. 

We have ourselves observed one case in the second year, and several 
othei-s between the close of the second and fifth years. 

The influence which sex exercises upon the frequency of rheumatism in 
childhood seems still undetermined. It is usually stated that boys are far 
more liable to the disease than girls, but in our own experience it has 
been more frequent in girls ; and from the register of the Children's Hos- 
pital in London (.quoted by Tuckwell, St. Barth. Hosp. Rep., vol, v, 1868, 
p. 102), it appears that of 478 cases of rheumatism treated during sixteen 
years, 252 were in females, and only 226 in males. The marked differ- 
ence in this respect between rheumatism in children and in adults may 
probably be explained by the fact that the two sexes are exposed to the 
exciting causes much more equally in childhood than in later life. 

Cold and Dampness. — Of external causes, the most prominent undoubt- 
edly are, sudden vicissitudes of temperature, especially when joined with 
dampness of the atmosphere, whereas the mere degree of coldness exer- 
cises but little influence upon its development. Of course the action of 
damp and cold is markedly increased by insufficient clothing. 

Onnplications. — We have already alluded to the occurrence of chorea 
and cerebral symptoms in connection with rheumatism (see article on 
chorea), and the most important and frequent of all these complications, 
the various inflammations of the membranes of the heart, have been 
treated of under the head of diseases of that organ. 

Pkck;nosis. — Uncomplicated rheumatism in childhood, though at times 
severe, is scarcely ever fatal. When complicated, however, with endo- or 
pericarditis, the gravity of the prognosis must depend upon the extent and 
severity of the inflammation. For although, even when the heart is seri- 
ously involved, the child frequently survives the acute symptoms, it too 
often bears with it the seeds of premature death, in an organic disease of 
that organ. 

DiAfJNOsis. — The diagnosis of acute rheumatism, after the appearance 
of the articular symptoms, can hardly present difficulty. When, however, 
marked rheumatic fever, accompanied merely by vague pains, precedes by 
several days the development of any local symptoms, the diagnosis must 
remain uncertain, or we may be led to regard as rheumatism one of those 
cases of phlegmon of the deep tissues of the extremities, such as is alluded 
to in the introductory esi«ay of this work. In addition to this, we must be 
careful to distinguish the articular affections occurring in pyaemia, or 
those supervening up^)n attacks of small-pox and scarlet fever, which are 
probably also of pyemic nature. The diagnosis in these cases must be 



648 ACUTE RHEUMATISM. 

chiefly established by atteution to the general symptoms and the patient's 
history ; to the occurrence of repeated chills or irregular febrile parox- 
ysms, the diarrhoea, the greater degree of prostration and more rapid ema- 
ciation, and the more frequent fatality. The joints involved in these latter 
affections present large collections of creamy pus, and the articular car- 
tilages are discolored, or eroded and destroyed in patches. 

Finally, Rilliet and Barthez cite a case (from Jour. Hehdomadaire, t. ii, 
p. 260) of haemorrhage under the periosteum of the clavicles, which sim- 
ulated rheumatic inflammation of the sterno-clavicular joints, but which 
could be distinguished by ordinary attention to the general symptoms, in 
case of the occurrence of such a rare condition. 

From our own experience we should think that, during the early stage 
of rheumatic fever, the affections with which it might be most readily con- 
founded, are pleurisy and pneumonia, and typhoid fever. 

The absence of the physical signs of the two former affections, and of 
the diarrhoea and delirium of the latter, should, we think, lead the phy- 
sician to suspect the rheumatic nature of the attack. And if, in addi- 
tion, there should be any fixed pain about the limbs, or unusual soreness 
and pain on being moved, or if any sign of cardiac inflammation be de- 
tected, this suspicion would be confirmed. Thus in a case seen by one of 
us, where at first the height of the fever and the great thirst led us to 
suspect the existence of pneumonia or pleurisy — of which, however, no 
physical signs could be detected — the occurrence, on the third day, of 
complaints of pain in the right groin, led to a more careful examination 
of the heart, where the presence of a soft, faint mitral murmur, declared 
the nature of the attack. 

Treatment. — The indications for treatment presented by acute rheu- 
matism have been universally recognized as uniform, but the measures 
adopted to meet them embrace almost all known remedies. 

The prominent indications are : 

1. To aid in the elimination of the rheumatic poison, which has set up 
the specific inflammations and fever. 

2. To relieve pain. 

3. To guard assiduously against all complications, and to aid convales- 
cence by suitable nourishment and tonics. 

Among the remedies which appear to be most productive of benefit, are 
alkalies, especially the bicarbonate of soda and acetate of potash, as recom- 
mended by Garrod ; the bromide of ammonium has also been used consid- 
erably of late, with apparent benefit. When the fever is very marked, 
nitrate of potash, in carefully graduated doses, is often beneficial. 

The iodide of potassium is most serviceable in cases of muscular rheu- 
matism, or in somewhat chronic cases of the articular form. Rilliet and 
Barthez assert that they have derived more benefit in the inflammatory 
complications of rheumatism (endo- and pericarditis, and pleurisy), from 
large doses of this salt than from any other drug. 

We are not aware of any observations which have been made upon the 
use of salicylic acid in rheumatism occurring in children, but from its 
well-established value in reducing the temperature and relieving the pains 



TREATMENT. 649 

of this aftectioD in adults, we have no doubt that it will be found of ser- 
vice in acute rheumatism in childhood. 

The remedies we have oui-selves found most useful, consist of acetate 
and bicarbonate of potash with opium, w^iich we are in the habit of giving 
during the acute stage, according to the following formula: 

R. — Potass. Acotftt., 3J. 

Potass. Bicarb., ...... ^j. 

Tr. Opii Deodor., Ctt. xxiv. 

vel Tr. Opii Camph., f:^ij. 

Syr. Zingiberis, ...... t^j. 

Aquie, . . . . . . . ad t^iij. 

Ft. sol. S. — A teaspoonful every two or three hours, at four or five years of ago. 

Iron, particularly in the form of Basham's solution of the peracetate of 
iron, should be given so soon as the intensity of the fever has mitigated. 
The necessity for this remedy is but too often seen in the sallow, antemic 
appearance of convalescents from rheumatism, which proves the rapid and 
extreme disintegration of the red corpuscles of the blood during an acute 
attack of this disease. 

When the acute symptoms have subsided, the alkalies may be dimin- 
ished and withdrawn, and quiiiia, in the dose of one grain every four hours, 
at the age of five years, may be given in connection with opium : 

The following formula is one we frequently use for the administration 
of these remedies in this and other conditions : 

R. — Quiniae Sulph., gr. xxiv. 

Liq. Morph. Sulph., f^ij. 

Acid. Sulph., Dil., gtt. xxx. 

Cura^oa, f^ij. 

Syrupi, f^^vj. 

Aquae ad f^iij. 

Ft. sol. S. — A teaspoonful every four hours, at four or five years of age. 

To fulfil the second indication, the mitigation of pain, opium must be 
given in proportion to the .severity of the suffering. It is best given in 
.small dorfes at short intervals, and by admiui.>-teriug it in combination with 
ipecacuanha, as in the form of Dover's powder, we derive the double ben- 
efit of a sedative and diaphoretic action. We have already given the 
formula by which we usually direct it in this di.sea.se. The inflamed and 
painful joint.s should be bathed with a sedative liniment, as of sweet oil, 
chloroform, and laudanum, and enveloped in bats of wool, and then cov- 
ered with oiled silk, so accurately applied as to exclude entirely the ex- 
ternal air. 

In addition to the other remedies, particular attention must be paid to 
the condition of the bowels, and if constipation exists, as is very frequent, 
mild saline laxatives or laxative enemata should be administered as 
frequently as required. Anything like purgation, however, should be 
avoided, on account of the excruciating suffering often produced by the 
movements necessary to have a stool. We desire, however, to call atten- 



6o0 



MATISM. 



tion to the fact that young children with this disease may persist in lying 
in one fixed position for even several days, dreading to be touched ; so 
that there is added to the inevitable pain of the disease, the distress occa- 
sioned by the long-continued contact of single points of the opposing artic- 
ulating surfaces. Under these circumstances it is wise, and greatly pro- 
motes the comfort of the patient, to gently change the angle of the limbs 
by arranging pillows so as to support them and alter their direction. 

In regard to the last indication — the prevention of complications — the 
most important means is the avoidance of all exposure of the patient to 
damp or to changes of temperature. In the fulfilment of this, the greatest 
care must be paid to the temperature of the sick-room, to the clothing of 
the patient, and to the mode of conducting all our examinations. Dr. 
Chambers, in his admirable lectures upon this subject {Clinical Lectures ^ 
American edition, pp. 156, 177, etc.), dwells with special force upon this 
point, and enjoins the exclusive use of blankets and flannels for the bed- 
ding and clothing of patients with rheumatism, and gives the following 
summary of his observations of the effects of this precaution alone in the 
treatment of nearly two hundred cases of rheumatism : "That bedding in 
blankets reduces from sixteen to four, or by three-fourths, the risk of in- 
flammation of the heart, diminishes the intensity of the inflammation when 
it does occur, and diminishes still further the danger of death by that or 
any other lesion." 

If, for any cause, local depletion should appear contraindicated, the 
immediate application of a blister is to be recommended. 

The importance of confinement to bed in this disease is difficult to over- 
estimate; the inflamed condition of the joints absolutely demands it, and 
the tendency to cardiac inflammation warns us to save the heart all un- 
necessary exertion, which strict attention, as above recommended, to the 
equable warmth of the surface, effects better than any other means. 

As to the diet in this affection, we must be guided by the acuteness of 
the symptoms and the condition of the patient. If the fever be marked, 
and the child vigorous, a diet chiefly consisting of milk and water is best 
suited to the early part of the attack, but so soon as the febrile stage has 
passed off, or when the patient is of feeble constitution, we may give soft- 
boiled eggs, and meat-broths, with advantage ; and frequently we will find 
concentrated nourishment and a moderate amount of stimulus required 
towards the close of the case. 

Complications. — In those cases where, despite our precautions, the 
membranes of the heart are threatened with inflammation, as evinced by 
sudden pain in the cardiac region, frequency of pulse, and oppression — 
even before the development of any murmurs — we should lose no time in 
employing local depletion by leeches or cups, abstracting as much blood 
as the urgency of the symptoms and the vigor of the constitution justify. 
After the removal of the cups or leeches, or blister, warm mush-poultices 
should be applied steadily over the whole prsecordial region. 



I 



DIPHTHERIA. 651 



ZYMOTIC DISEASES. 



Under this title, as already stated, we include those acute general dis- 
eases whicli are dependent upon the action of some infectious morbid prin- 
ciple introduced into the system from without. They embrace a non-erup- 
tive group, of which we shall describe diphtheria, mumps and malaria, 
epidemic cerebro-spinal meningitis, and the group of eruptive fevers. 



ARTICLE II. 

DIPHTHERIA. 

Definition ; Synonyms ; History ; Frequency. — Diphtheria is an 
acute febrile, moderately contagious, and infectious asthenic blood disorder, 
occurring both endemically and epidemically ; without characteristic erup- 
tion, and distinguished by a disposition to the formation of false mem- 
branes upon inflamed mucous surfaces, especially in the fauces, or upon 
abrasions of the cutaneous surface. 

It is the disease called by the older writers, angina maligna or gangre- 
nosa ; cynanche maligna ; garotillo ; angina suffocativa, under which name 
it was described by Dr. Samuel Bard, of New York, in one of the best of 
the early essays upon this subject (Trans. Amer. Philos. Soc, vol. i). 

It is, indeed, thought probable, that the history of this affection can be 
traced back to a period beyond the time of Hippocrates ; but unquestion- 
ably the writings of Aretieus, who flourished in the second century of the 
Christian era, contain a distinct description of this malignant sore throat. 
He describes it under the names of ulcus Syriacum and malum ^Egypti- 
acura. 

From this period, there is quite frequent mention of the disease in the 
works of medical writers ; the earliest account of its appearance in modern 
times being given by Hecker, who describes an epidemic of it that prevailed 
in Holland, in 1337. 

About the middle of the last century, it prevailed in Paris, where it was 
describe*! by MM. Maloniu and Chomel ; and in some parts of P^ngland, 
where it was studied and described by Fothergill, though it is now doubted 
whether the disease to which he refers was not more nearly allied to scar- 
latinous angina. 

The first full description of this affection published in this country, was 
the paper, already referred to, by Dr. Bard, based upon an epidemic which 
ap|>eared in 1771 ; the views advanced in which have been universally 
recognizeil, even to the present day, as most clear and just. 

From that time, the complaint seems to have attracted but little atten- 
tion, until its occurrence at Tours, in 1818, and subsequent years, called 
forth the treatise of Bretonneau in 1826, in which he gave the first precise 
notion of the disease, and Ijcntowed the iiaiue difjhthcrite upon it. 



652 



DIPHTHERIA, 



^ 



Siuce then it has occurred frequently epidemically in France ; in 1857 
it appeared almost simultaneously in England, and in the extreme western 
part of our own country, and from that time has occurred in the form of 
epidemics of greater or less extent and severity, in the most varied climates 
and seasons, in almost all known parts of the globe. 

Diphtheria, the name by which this epidemic pseudo-membranous angina 
is commonly designated, is a synonym of the word diphtherite, originally 
used by Bretonneau in his treatise on this subject. 

At<pO£pa and AifOepo^ both mean " the prepared skin of an animal ; " 
and AcfOspivqq and Jt<p6£pcaq signify alike, " that which is covered with a 
skin or membrane." 

No cases of death from diphtheria in Philadelphia are reported in the 
annual lists of mortality published by the Board of Health, until the year 
1860. In the preceding report, however, Dr. Jewell mentions that several 
severe cases had occurred, some of which had proved fatal. One of us 
can, however, assert from his personal experience, that well-marked cases 
of diphtheria were of not rare occurrence in this city for a number of 
years before that time, but were reported under other names, and usually 
as either croup or angina. 

It is probable, however, that the disease did not prevail at all extensively 
previously to its great outbreak in 1860, as may be seen by a reference to 
the number of deaths from croup and scarlatina, returned for the years 
preceding and subsequent to that date. 

TOTAL NUMBER OF DEATHS FROM 

1855, 
1856, 

1857, 
1858, 
1859, 
1860, 
1861, 
1862, 
1863, 
1864, 

The total number of deaths from scarlatina, from 1855 to 1859 inclusive, 
were 2332; from 1860 to 1864 inclusive, 1620, or 712 less than in the pre- 
vious period. 

The total number of deaths from croup from 1855 to 1859 inclusive, 
were 1393 ; from 1860 to 1864 inclusive, 1815, or 422 more than in the 
previous 5 years. And, further, during the latter 5 years, 1860 to 1864, 
the deaths from diphtheria amount to 1925. 

Causes. — In regard to the epidemic and occasionally endemic nature of 
diphtheria, the evidence is unanimously favorable, but it is still, to a cer- 
tain extent, an open question as to how far it possesses contagious and infec- 
tious properties. 

Numerous authorities might be cited in favor of either of these to the 
exclusion of the other ; but the evidence adduced convinces us that diph- 



Scarlatina. 


Croup. 


Diphtheria 


. 163 


265 




. 992 


268 




. 704 


256 




. 241 


292 




. 232 


312 




. 206 


354 


307 


. 829 


304 


502 


. 461 


258 


325 


. 275 


444 


434 


. 349 


455 


357 



I 



CAUSES. 653 

theria is both contagious and infectious also, though to a moderate degree 
only. 

Bard, Trousseau,^ Guersant, Valleix,- (who has himself fallen a victim 
to this disease), Rilliet and Barthez,' Wood,* Empis,^ and many others, 
attest to its contagiousness ; and we have ourselves seen unmistakable 
instances in our own practice. 

Brettoneau* also maintains strongly the infectious nature of diphtheria, 
and holds that it is transmitted directly by contact with the morbid prod- 
uct generated by the local disorder, i. e., the pseudo-membrane ; and it 
must be admitted that the ca*es now on record, in which the disease has 
been so transmitted, are too clear and well authenticated to permit of doubt. 

Apart from these well-ascertained properties, nothing is as yet known 
with regard to the general conditions which favor its production ; and it 
appears to have prevailed with equal severity in healthy and unhealthy 
situations; in damp marshy districts and in dry hilly regions; in the 
crowded filthy houses of great cities, and in sparsely populated villages ; 
in the depth of winter and in the intense heat of summer. 

Nor can it yet be positively asserted (although it is probably true with 
regard to diphtheria, as in the case of other zymotic diseases), that chil- 
dren of feeble constitution and those subjected to bad hygienic conditions, 
or debilitated by severe illness, are particularly exposed to it, especially in 
the sporadic form. 

Of late years, we have been inclining to the opinion, although as yet 
any positive evidence is wanting, that the prevalence of diphtheria and 
especially its virulence, are favored by defects of drainage and by con- 
tamination of the air and drinking-water. 

The effect of local causes, of a depressing character, upon the produc- 
tion of diphtheria, was investigated by Dr. Ballard,^ in regard to 57 fatal 
cases. Inquiries at the houses where the 57 deaths had occurred, showed 
that in 24 instances the houses were damp, and that defective drains or 
some similar cause gave rise to offensive smells ; in four houses the in- 
mates were overcrowded, and the ventilation deficient ; in 8 cases, the 
drinking-water was foul, or there was some noxious accumulation ; and in 
25 cases, nothing whatever could be discovered amiss in the hygienic con- 
dition of the houses. 

It is certain, however, that occasionally diphtheria appears in a sporadic 
form, and Isolated cases occur which can be attributed to no known cause 
whatever. 

We subjoin a table of the mortality from croup and diphtheria in this 
community during the seven years from 1862 to 1868 inclusive; upon 
which we base, to a great extent, the remarks which follow as to the causa- 
tion of the latter disease. 

» Clin. Med., 2^me ed., 18'J5, t. i, p. 385. 

» Guide du Med. Prat., 4*me ed., 1801, t. i, p. .')30. 

» Mai. de« EnfanU, 2^me od , 1853, t. i, pp. 843-309. 

* Pract. of Medicine. 0th ed , 1800, vol. i, pp. .505-525. 

' Memoirs on Diphtheria (New 8yd. Soc. ed., 1859), p. 332. 

• Id. Op., pp. 127 and 177. 

"> Med. Times and Gaz., July 23d, 1859. 



654 



DIPHTHERIA 



I 



00 
CO 

oo 



> 

M 



Oh 
O 

o 

o 



H 
t 

o 



Siiianp uit!>i 


^ 


CO 




00 


b- 


S 


05 
CO 


1>. 






CO 


05 


<M 


?J 


. 




CO 




CO 


05 


Oi 


7M 


co 




CO 




CO 


00 


• 




JoiiM UBOK 


CO 


'^ 


Tt< 


CO 


10 


»o 


CO 


■^ 





CO 


CO 


CO 


• 












































jojeainujocluiox 


r^ 





«o 


t^ 


l^ 


l^ 




CM 







00 




. 




00 


00 


00 


!M 


t^ 


Oi 


t^ 


CO 


CO 


CO 


CO 


f- 


. 




uuoH 
























Tt* 






CO 


CO 


"^ 


10 


CO 


t- 


t^ 


t^ 


CO 





Tf 


CO , 










id 

5S 




CO 

16 




CO 
CO 


1—1 


00 

CO 


CO 


00 

CO 


CO 
c» 


CO 

CO 


CD 


CO 


CO 

on 


• 




«^ 


(M 


(M 


CM 






1— 1 




l-H 


CM 


(M 


CM 


CM 


^ 




1^ 
































a 


1 CO 


Tin 


t^ 


Ico 


CO 


t- 




00 


CD 


"* 


CO 


t^ 


. 




'^ 


i^ 


-rq 


CI 


Oi 


^ 











CJS 


00 


,_, 






gM 


O 


TT 


(M 


CO 


CM 


'"' 


T— 1 






CM 


(M 


CO 


"* 


• 






i_c« 


(M 


t^ 


CO 


CM 





^ 


CD 


Tt< 


t- 


QO 


CM 


CM 


00 






























CM 






od 


f^5 














. 












r-{ 




CD 
































00 


































































3 


Tt^ 


00 


00 


CD 


,_H 





Tt* 


00 





CD 


Oi 


iM 


CD 








CO 


















<M 


CM 


CO 









O 


























CM 










ii 


t^ 


Oi 


t- 





Oi 


CO 


t^ 


00 


to 


^ 


00 


^ 


00 






.— 0) 


T— 1 




r-H 


I— 1 












rH 




rH 


rH 




t^ 


'^5 


























rH 




CO 
































CO 


































a, 
































3 


C^ 


CO 





i-H 


(M 


CO 


on 


CO 


■^ 


10 


CD 


10 









2 


CM 




<M 


CM 












!M 




CO 


00 






o 


























""* 






j=.s2 


"^ 


Oi 




GO 


Oi 


C<l 


CM 


to 


CO 


CO 


00 


lO 


CM 






■^ 2 


(M 


T— 1 


!M 




rH 


r-t 


r-\ 


T— 1 


rH 


rH 


r—\ 


rH 


Oi 




o 


Mis 


























f— ' 




CD 
































00 


































&, 
































s 


CO 


r— 1 





CO 


t^ 


,—1 


■* 


(Tfl 


TtH 


(M 


rH 


00 


OS 






O 


TfH 


CO 


CO 




(M 


,—1 








CM 


CM 




CO 






























CM 










JL c« 


































CO 





00 


(M 


(M 








■^ 


CM 





Ci 





13 






•^=^ 


CO 


CO 


•M 


CM 




<M 




rH 




CM 


CM 


CM 


CO 




uo 


05 


























^ 




































§ 


































c 


































Tt( 





rt< 


CO 


00 


CM 





10 


1— 1 


CO 


CO 


CM 












Tt< 


10 


Tti 


cs 






t— 1 


1 — 1 


CM 


CO 


TJH 


CO 

































CO 






X cS 












T 






















1-^ 


CO 


CO 


10 


I>- 


rJ 


CM 





-^ 


t^ 


rH 


TjH 


t~- 






.S-o, 


(M 


(M 


'"^H 




(M 


CM 


CM 


CO 


CO 


■^ 


CO 


CO 


10 




■^ 


05 


























CO 




CD 
































00 


































a. 
































s 


05 


Oi 


(M 


CD 


,—1 


Oi 


rH 


05 


>*l 


CO 


j—i 


,—^ 


»o 






k; 






CO 


CD 


CO 


-rJ^ 




rH 


I— 1 


CO 


CO 


10 


10 

































TtH 








Ttl 


(N 


"* 




I— 


00 


CO 


lO 


c» 


CO 


"^ 


CM 


■^ 






.r^o 


CO 


rfi 


<M 


CO 


>— 1 


rH 


CO 


CO 


CO 


CO 


CO 


CO 


CO 




CO 


Q-a 


























-* 




CO 
































00 


































































3 


CD 


t~ 


CD 


Tt< 


1— 1 


t- 





(M 





CJi 


Oi 


tr- 


CO 






2 


CO 


T^i 


!M 


CO 


rH 


I— 1 


3^ 







Tti 


CO 


cx> 


TJH 

































T)H 






H 








CO 


■M 


(M 


(M 


tH 


■^ 


tH 





CM 


05 


to 






CO 


rt< 


CJ 


(M 


3^ 




CM 


CM 


CM 


"■Ji 


CO 


CM 


CM 




'M 


Q-S 


























CO 




CO 
00 


















































1 














5* 


































Tt* 


-rt< 


05 


>o 


t^ 


t^ 


00 


l^ 


CO 


00 


CO 


l^ 


00 









rt^ 


tM 


CM 


rH 


r— ( 












CO 


CO 


>o 






























(M 






^ 


^ 












^ 


^ 




^ 


^ 








^ 


>> 














V 




O) 




7 




1 


a 

c 


a 


1 






c 


^ 

^ 


(/I 

3 
b/) 

< 1 


s 


CD 

1 

6 


s 

> 



s 



a> 




H 





J 



NATURE. 



655 



Season. — As we have already remarked, the influence of season upon 
the prevalence of diphtheria is comparatively slight, and there are nu- 
merous records of epidemics occurring in the summer, as well as in the 
winter months. Notwithstanding, however, it will be seen that in our 
own city the mortality from diphtheria does not vary very much during 
the months from September to March inclusive, whilst during the other 
five months it falls off from thirty to fifty per cent., the minimum mor- 
tality usually occurring in June. We have before had occasion to allude 
to the diflTerence, in this respect, between diphtheria and croup, which latter 
disease shows in the clearest and most marked manner the direct influence 
of season upon its frequency. 

Thus croup is far most frequent during the three months of November, 
December, and January, and, with the exception of February, becomes 
less and less frequent as you leave these months in either direction, until 
during July, the hottest month of our year, it fiills to even less than one- 
fourth of its maximum frequency. During the same month, diphtheria, 
whose maximum mortality is one-third less than that of croup (both 
maxima occurring in December), causes more than half as many more 
deaths than croup does, the proportion being 16.3 to 10. 

Sex appears to have absolutely no influence upon the frequency of 
diphtheria, since of 1804 fatal cases occurring in this city during the above 
seven years, 901 were males, and 903 females. 

Age, on the other hand, unquestionably exerts a very strong predispos- 
ing influence, a large majority of all recorded cases occurring between the 
ages of one and eight years. 

Of the 1804 cases in our table, 190 occurred under the age of one year; 
335 between one and two years ; 725 between two and five years, and 355 
between five and ten years. Although the liability thus diminishes, in an 
uncertain ratio, with advancing years, no age is exempt from it. By 
reference to the influence of age upon the frequency of true primary croup, 
it will be seen that the maximum of its frequency is also attained between 
the ages of one and five years. We would also call attention to the much 
greater frecjuency with which diphtheria occurs in later life than croup ; 
since of 2136 deaths from croup, but 77 were over ten years of age; while 
of 1804 deaths from diphtheria, not less than 199 occurred after that 
periml. Of course it is evident that the above statistics not only prove 
that diphtheria is much more frequent during the first decade of life than 
at any subsequent period, but also that it is much more fatal then. 

Natirk. — In his earliest writings upon this subject, Brctonneau at- 
tached little importance to the constitutional symptoms attending diph- 
theria, and upheld the view that it was essentially a local affection ; and 
though he subsequently somewhat modified his views, he yet only admitted 
that the constitution becomes involved secondarily. 

It is indeed true that the epidemics which have occurred during the past 
twenty-five years seem to have been attended by far more grave constitu- 
tional symptoms than were present in the cases upon which Brctonneau's 
memoir were founded. And at present, it appears to us, that a careful 
study of the very numerous reports of epidemics occurring in all parts of 



6oQ DIPHTHERIA. 

Europe, Great Britain, and the United States, especially during the past 
ten years, can leave no doubt upon the mind that diphtheria is a blood 
dis^ease, attended with marked constitutional disturbance, which is usually 
of a decidedly asthenic character. 

This view is at present almost universally adopted ; and in accordance 
with it, we find diphtheria removed from the place which it formerly held 
in systematic treatises, among the local affections of the pharynx, and dis- 
cussed as one of the general diseases. 

The chief arguments in favor of its being a constitutional disease, are 
its epidemic and contagious nature ; the continued febrile action, of 
asthenic type, which attends its course; the marked alteration of the blood 
mass in color and consistence ; the tendency to pseudo-membranous exuda- 
tion on mucous membranes, or abrasions of the skin ; the occurrence of 
albuminuria ; and, finally, the frequent development of paralytic sequelae, 
showing the presence of some morbid agent, acting especially upon the 
nervous system. 

Bouchut,^ to a certain extent, agrees with Bretonneau. He divides 
diphtheria into false, or non-infecting, which is mere pseudo-membranous 
angina ; and the true, or infecting, which involves the entire system, by 
means of the absorption of septic substances from the pharynx. In this 
respect it resembles pyemia, and produces swelling of the lymphatics, 
alteration of the blood, albuminuria, and even metastatic deposits. 

Pathological Anatomy. — False Membranes. — We have already dwelt 
upon the fact, that the pseudo-membranous exudation can no longer be 
regarded as the essential and most important element in diphtheria ; it 
is, however, one of the most constant and striking phenomena, and in 
certain cases, where it extends into the larynx, becomes the eifective cause 
of death. 

It has been most carefully studied in regard to its mode of development 
and extension, seat, and microscopic characters, by Empis, Bretonneau, 
Wade,^ Thompson, Darrach,'* Trousseau, Sanderson.* 

Mode of Development. — When fully developed, the pseudo-membranous 
deposit has the ordinary appearances of a fibro-plastic membrane ; but 
this stage is preceded, according to the researches of Empis and others, by 
the exudation of a sero-mucous, transparent, and viscid fluid, which varies 
in abundance in different cases, at times even forming, as noticed by Trous- 
seau and Empis, in the neighborhood of parts lately covered by deposit, a 
sort of submucous exudation, suflicient to raise the epithelium in the form 
of phlyctense. 

This sero-mucous liquid does not long remain transparent and diffluent, 
but soon becomes a little less transparent in points^ gains a yellowish tint, 
acquires greater density, and adheres more strongly to the subjacent mucous 
membrane. These points, at first isolated and circumscribed, soon coa- 

1 Mai. des Enfants, 4feme ed., pp. 907-923. 

2 London Lancet, February 5, 1859 [et cmie). 

3 Trans. Coll. of Phys. of Phila., February 6, 1861 (Araer. Jour. Med. Sci.). 
* Brit, and For. Med.-Chir. Rev., Jan. 1860. 



PATHOLOGY AND ANATOMY. 657 

lesce so as to form a «1elicate pellicle, but slightly cohering, and capable 
of being raised from the mucous membrane by slight traction ; although, 
owing to its friability, it is dithcult to raise a piece of any considerable 
size. 

TJiis pellicle is more dense and thick at its centre than towards the edges, 
and soon after its formation, the exudation continuing beneath it, and co- 
alescing with it, it gains in thickness by the apposition of an under layer; 
until, when the membrane is fully developed, it may consist of several 
layers, and appear imbricated. 

At this j)eriod its adhesions are so strong that, if it be detached from its 
connections, slight haemorrhage will follow, or numerous minute bloody 
points may be seen upon the subjacent mucous membrane. 

According to Empis, the appearance of the opaque spots in the clear 
sero-mucous Huid is due to a precipitation of fibrin independently of any 
agency of living tissue. Thus the tubular casts which form in the air-pas- 
sages are rarely adherent, and are usually much sn^aller than the cavity 
occupied; and in cases of tracheotomy he has noticed the canula to become 
lined within a few hours with a layer of whitish concretion, the thickness 
of which continually increased, and which was evidently only the result 
of coagulation of the liquid by which the sides of the canula were con- 
stantly covered. 

Color. — The color of the pseudo-membrane varies at different stages, and 
somewhat according to its seat. 

In the fauces, the deposit is often whitish at first, but soon acquires a 
yellow tint; though in some cases it is quite gray, and produces the appear- 
ance of extensive sloughs on the fauces and pharynx. In severe cases, 
there is usually a bloody sanious fluid effused, which imbues the pseudo- 
membrane, discolors it, and promotes its decomposition, so that it forms 
dark-colored shreddy patches, exhaling a fetid, gangrenous odor. 

It is essential to bear in mind that these appearances of the fauces in 
diphtheria are usually due to decomposition of the false mem))ranc alone; 
and that, if this be removed, the mucous membrane will generally l)c found 
merely raw, excoriated, and oozing blood. 

It is, however, true that in certain epidemics the rule has been for seri- 
ou.« lesions of the mucous membrane, involving even its entire thickness, to 
occur. 

In milder cases, where the disappearance of the false membrane can be 
studied, it is never seen to separate all at once, leaving in its place a cica- 
trized surface, but the pH-llicle gradually diminishes in thickness and extent. 
"When the })seudo-membrane extends into the larynx, it is more apt to re- 

ain whitish throughout its course there than in the fauces. 

Cojufi^ence. — The consistence of these deposits varies considerably. In 
' u-es of ordinary severity, where the symptoms are not of a very adynamic 
type, the pseudo-membrane is often quite firm, tenacious, and elastic ; while 
in grave asthenic ca.«es, with .severe inflammation of the throat, the depo^it 
is apt to be much less firm, or even quite pultaceous. 

It has been attempted to base upon these conditions and corresponding 
microscopic appearances, a divi.«jion of diphtheritic pseudo-membranes into 

42 



658 DIPHTHERIA. 

two classes, answering to the well-known division of inflammatory lymph 
into the fibrinous and the corpuscular. 

Microscopic Anatomy. — There were formerly different views entertained 
with regard to" the minute anatomy of the pseudo-membranous deposits 
in diphtheria. -• 

Vogel originally associated with the disease the presence of the oidium 
albicans, the parasite which we have seen to be characteristic of muguet ; 
and, more recently, Laycock, of Edinburgh, has insisted upon the occur- 
rence of this cryptogam in the pseudo-membranes of diphtheria. 

Dr. Wade, of Birmingham, has noticed also in some cases, in or near the 
exudation, the spores of the leptothrix buccalis, a fungus very commonly 
met with in the secretions of the mouth and pharynx. 

Further investigations have shown, how^ever, that these parasites are 
occasionally present in numerous diseased conditions of the mouth and 
fauces, and that their occurrence in diphtheria is to be considered as a 
mere accident, and not as an essential part of the affection. 

The microscopic appearances which are constant, are the ordinary ele- 
ments of corpuscular lymph : exudation cells or even pus-corpuscles, gran- 
ule-cells and free fatty granules, and more or less abundant and closely 
interlacing fibrillse, mixed with epithelial cells of various shapes and sizes. 
In the majority of specimens, the corpuscular elements greatly predomi- 
nate, the fibres being few and small ; and indeed it is only in the firmer, 
more tenacious, pseudo-membranes that mucii true fibrillation is noticed. 

Chemical Characters. — The false membranes contract and shrivel when 
treated with alcohol ; mineral acids, such as sulphuric, muriatic, nitric, or 
chromic ; strong solutions of nitrate of silver ; or solutions of the per-salts 
of iron. 

On the other hand, they soften more or less quickly when treated with 
alkaline solutions, as of potassa, soda, lime, or ammonia ; or of chlorate 
of potash, chlorate of soda, bromide of potassium ; or with glycerin and 
various other agents. Recently, pepsin and lactic acid have also been 
announced as powerful solvents. These various chemical properties are 
■constantly turned to account in the treatment of diphtheria, in guiding 
our selection of the most appropriate local applications. 

Condition of the subjacent Mucous Membrane. — Even before the appear- 
ance of the slightest exudation, the mucous membrane of the fauces is 
often seen to be red and somewhat swollen. After the pseudo-membrane 
is fully developed, it is of course impossible, without forcibly detaching 
it, to gain any idea of the condition of the mucous membrane beneath, 
and unquestionably very many of the descriptions given of extensive gan- 
grenous ulceration of the fauces and pharynx, have referred merely to the 
changes in the pseudo-membrane due to its decomposition and the im- 
bibition of sanious fluid. 

In the vast majority of cases, the subjacent mucous membrane is not 
truly ulcerated, but is merely much congested and swollen, with an exco- 
riated and roughened appearance from removal of its epithelium, and oc- 
casionally presents spots of ecchymosis. 

At times it is whitish, opaque, or unnaturally pale ; while in other cases 



SEAT OF TUE EXUDATION. 659 

it is purplish or otherwise discolored. When the depos^it is raised up, es- 
pecially if it be of. the firmer variety, it is often seen to be attached to the 
surface beneath by numerous small filaments, as though processes of the 
deposit passed into the mucous follicles. 

Although these may be considered as the most usual conditions of the 
mucous membrane, it is undoubtedly true that in some cases extensive and 
deep ulceration, and even gangrene occur, exposing the muscular tissue of 
the pharynx, or even producing the destruction by sloughing of an entire 
tonsil gland. 

This accident occurs much more frequently in some epidemics than others, 
as may be readily seen by a comparison of the accounts given by different 
authors of the anatomical lesions noticed in the epidemics they have re- 
spectively studied. 

The submucous tissue is often edematous, infiltrated with bloody serum, 
or is the seat of an interstitial exudation of lymph. In some cases the 
cesophagus and the muscular tissue around the fauces and pharynx are 
congested and infiltrated. 

When croup ensues, the mucous membrane of the larynx and trachea 
is more or less swollen and congested, and, according to West, presents dis- 
tinct erosion of its surface, with small ulcers about the edges of the glottis, 
in a larger proportion of cases than ulceration is met with in the fauces. 
M. Isambert* suggested that this condition might serve to distinguish diph- 
theritic from idiopathic croup; but West has met with precisely similar 
ulceration of the mucous membrane of the larynx in cases of primary 
croup, and is disposed to regard its presence or absence as mainly depen- 
dent on the rate of progress of the disease towards a fatal termination.^ 

Seat of the Exudation. — The pseudo-membranous deposit is usually 
first seen upon the tonsils and soft palate, and in some cases is limited to 
these parts throughout the whole course of tlie case. 

Frequently, however, the exudation spreads and coats the i)haryux more 
or les3 extensively, or extends into the posterior nares, or downwards 
through the larynx into the trachea and bronchi, or more rarely into the 
CES^)phagus. 

It is rare for any exudation to occur on the mucous membrane lining 
the cheeks, or upon the gums, though according to some authors, as Hutch- 
inson,' Trousseau, and Bouchut, ulcerative stomatitis is in reality buccal 
diphtheria. The epiglottis is at times covered with a pseudo-membranous 
deposit, so as to become swollen, rigid, and almost immovable, and hence 
partially obstructing, without being able to protect, the entrance into the 
larynx. 

The tendency for the exudation to extend into the nasal passages varies 
much in different epidemics, and when present, almost always betokens 
the great gravity of the caae. 

* Arch. Gen. de M^d., March and April, 1857. 
« Dii-eascs of Children, 4th Am. fd., 18G0, p. ;i5G. 
» Med. Times and Gaz., 3Iarch 19lh, 1859. 



660 DIPHTHERIA. 

AccordiDg to Bretonneau, the exudation occasionally begins in the nares 
and extends thence in so insidious a manner as readily to escape detection. 

We will discuss more fully the questions relating to the extension of the 
exudation into the larynx under the head of diphtheritic croup. 

The diphtheritic pseudo-membrane is not, however, limited to these 
mucous surfaces, but is occasionally seen, and especially in very severe 
cases, to form upon the mucous membrane of the vulva or of the anus. 

It is, moreover, a most significant fact in regard to this affection, that 
any portion of the external cutaneous surface which has been denuded of 
epidermis, may become the seat of this deposit, and that in some cases the 
pseudo-membranous formation is even limited to the skin, constituting the 
so-called external or cutaneous diphtheria. So far, however, from the at- 
tending constitutional symptoms being less severe in the external than in 
the ordinary form, the tendency to deposit upon the cutaneous surface 
usually presents itself in cases of a typhoid adynamic type. 

It appears, indeed, that this pseudo-membrane may occur at any point 
of the body to which the atmospheric air has access; but it has never been 
noticed on parts which are removed from its influence. 

Notwithstanding these apparently distinctive features of the diphtheritic 
deposit, it is impossible l)y mere ocular or microscopic examination to dis- 
tinguish it from the pseudo-membranous deposit in cases of ordinary scar- 
latinous angina. 

It is more, therefore, in the peculiar constitutional disturbance that we 
must look for the specific nature of diphtheria, than in the presence and 
characters of the false membranes. 

The Suhmaxillary Glands are almost always enlarged, though they 
rarely acquire the enormous size and peculiar brawny induration so often 
noticed in scarlatina. It is, moreover, very rare for this condition to ter- 
minate in suppuration of the gland. 

The Heart has been found, by Hillier,^ in a state of fatty degeneration 
in two cases; and by Bristowe {id. loc.) in one; all of which were rather 
chronic. We have observed marked granular degeneration of the cardiac 
fibre in several instances, however, where the disease had been of a violent 
and rapidly fatal form. In some instances where symptoms of endocar- 
ditis were present during life, the auriculo-ventricular valves have been 
found in an incipient stage of inflammation. (Bridger.^) We have also 
observed in several cases, in at least one of which a valvular murmur was 
heard during life, incipient inflammation of the mitral valve, with rows of 
minute, delicate, beadlike vegetations fringing the free -borders of the leaf- 
lets. In other cases, pericarditis has been developed during the course of 
diphtheria. We desire to call particular attention to these cardiac com- 
plications, on account of their great importance as influencing not only 
the prognosis of the attack itself, but possibly also the subsequent develop- 
ment of chronic cardiac disease. 

Heart-clots of large size and firm consistence, evidently of ante-mortem 

1 Diseases of Children, Am. ed., 1868, p. 154. 

^ Med. Times and Gn/.., Jan. 1864, p. 201 ; and Brit. Med. Jour., Oct. 22d, 1864. 



t 



SYMPTOMS. 661 

formation, are also foiiml in a certain number of cases where death has 
been preceded by peculiar signs of circulatory embarrassment. 

The Lungs are not rarely found inflamed and consolidated to a greater 
or less extent. In other cases the exudation is found penetrating deeply 
into their structure, filling the smaller bronchial tubes, and the lung itself 
is in parts collapsed or carnified. 

Bouchut speaks of having seen small apoplectiform patches, similar to 
those which precede the so-called metastatic abscesses in pyaemia. 

The Kidneys are at times quite healthy ; in other cases, however, they 
have been found congested, and the renal epithelium granular and de- 
tached, so as to distend the tubules, which also contain fibrinous casts 
( inclosing granules of hoematin, blood-corpuscles, or a few altered epithelial 
cells). (.Hillier (he. cif.), Greenhow,' etc.) 

The ga^tro-inte'Sfinal canal presents no lesions of importance ; in a few 
cases enlargement of the solitary glands of the lower })art of the ileum 
has been noted. 

Secondary Form. — When diphtheria appears in the secondary form, the 
raucous membrane is more violently inflamed. It is of a deep red color, 
rough, and very much thickened and softened. The tonsils are large and 
soft, uneven, and often infiltrated with pus. In addition, the mucous 
membrane is far more frequently and seriously ulcerated in this form than 
in the primary. False membranes are almost always present, generally 
on different portions of the fauces, and more rarely over their whole ex- 
tent. They are generally rather soft and thin, of a whitish, grayish, or 
yellow color, dispersed in fragments and easily torn. 

The inflamed parts are usually bathed in a purulent fluid. The sub- 
maxillary glands are large, red, and soft ; and, in addition, there may be 
found various lesions of other organs, due to the primary disease, in the 
course of which the diphtheritic angina has been developed. 

Symptoms. — Diphtheria occurs both in a sporadic and epidemic form ; 
it a\>o presents itself either as a primary or secondary aflectiou. The 
symptoms of this latter form are, however, so involved with the symptoms 
of the diseases in the course of .which it is developed, that it seems desira- 
ble to consider it in connection with them severally. 

It would a|)pear that, under the influence of widespread epidemic in- 
fluences, the symptoms of diphtheria have of late years presented a higher 
degree of .severity. Owing to the fact, however, that, until the descrip- 
tion of diphtheria by Bretonneau, it was confounded with anginose scarla- 
tina, with ulcerated sore throat, etc., it is extremely difficult to form a 
correct comparison between the disease as we are now familiar with it, and 
as it undoubtedly occurred in former years. 

In a strictly systematic discussion it might be well to divide dij)hth<'ria 
into a mild form, which would include most sporadic cases and many of 
the epidemic ones, and a severe form, under which head would he com- 
prised all cases distinguished by a high degree of constitutional disturb- 
ance. For practical purposes, however, it is suflScient to give a descrip- 

1 On Diphtheria, New York, 1861, p. 160. 



662 DIPHTHERIA. 

tion of the ordinary course of the disease, dwelling upon some of the most 
important symptoms, and alluding to the chief peculiarities which at times 
present themselves. 

Local Symptoms. — Examination of the TJiroat — The onset of diph- 
theria is often very insidious ; so that our attention may not be called to 
the throat by any complaint of the patient, even when a considerable 
amount of exudation is already present. 

If the throat be examined, however, on the first day of the disease, the 
exudation may often be found even at that time, though it is sometimes 
not found before the second day. The fauces generally present more or 
less swelling and redness prior to the appearance of the false membrane, 
which almost always shows itself first on one of the tonsils only, in the 
form of whitish or opaline spots, like coagulated mucus, which soon run 
together and extend over the whole gland, and then to the soft palate and 
pharynx, though it sometimes remains limited to the tonsils and soft 
palate. A little later in the attack the plastic deposit exists in the form 
of layers of greater or less extent; it has lost its transparency, become 
firmer in consistence, thicker, and changes from a white to a yellowish- 
white or lardaceous, and sometimes grayish color. 

The breath in this case is offensive, but not fetid ; and there is but little 
salivation. 

When, in favorable cases, the disease is left to pursue its natural course, 
the pseudo-membrane becomes thinner, assumes a grayish tint, and falls ofi" 
about the sixth or seventh day. When, on the contrary, topical remedies 
are applied to the throat, the membrane is often detached after one, two, 
or three days, but may be reproduced several times before the conclusion 
of the case. 

In some unfavorable cases, on the contrary, even though the exudation 
may disappear more or less completely from the pharynx, it extends down- 
wards into the larynx, and we have true croup developed, which but too 
often proves fatal in spite of all remedies. 

In more violent cases, the pseudo-membrane, about the time that it begins 
to be detached, assumes a grayish or blackish color, and hangs in shreds 
from the surfaces to which it was attached. The fauces, under these cir- 
cumstances, present a gangrenous aspect, the mucous membrane having an 
appearance as though it were falling off in sloughs ; the breath is extremely 
fetid, and there is more or less abundant salivation, or in some cases an 
expuition of sanguinolent fluid. 

There can be no doubt that it was from misconception of such cases as 
these, that the titles of gangrenous and putrid sore throat arose. 

As the exudation disappears from the pharynx, the swelling of the parts 
affected gradually subsides. The mucous membrane, from which the plastic 
matter has just fallen, is more or less injected and red ; the tonsils and soft 
palate are sometimes found to be reduced below their natural size. 

Even when the throat affection is very severe, there is not often so much 
difficulty in opening the jaws nor in deglutition as is met with in scarlatina. 

The submaxillary glands are almost always enlarged and slightly painful 
to the touch, about three or four days after the appearance of the pseudo- 






1 



SYMPTOMS OF DIPHTHERITIC CROUP. G63 

membraue. The enlargemeut is usually irroatost on the side where the 
inflaniiiiation of the tauees is most intense. The surroundinii- eellular 
tissue shares in the intlanimation, so that the swelliui:: is often verv ij^reat, 
and impedes the movenients of the jaw ; it is rarely, however, save in 
very had eases, so hard and painful as the corresponding swelling in sca»'- 
latina. 

Piiin and Difficultij in Derjhitition. — Tliere is sometimes no complaint of 
pain in the throat, although, even at the outset, swallowing is usually 
somewhat difficult and painful, and pressure behind the angles of the jaw 
causes a moderate degree of suffering. In some cases, especially of the 
sporadic sthenic form, the earliest symptom may be excessive pain on 
swallowing. 

As the pseudo-membranous exudation increases, and the submaxillary 
glands become swollen and tender, deglutition becomes more difficult and 
painful, and, at times, attempts to swallow fluids are followed by cough 
and the return of the fluid through the nostrils. 

In cases where the false membranes decompose and acquire a gangrenous 
aspect, and typhoid symptoms are present, the pain and difficulty in swal- 
lowing, if they have existed, are apt to disappear. 

Varieties depending upon Extension of the Exudation. — 1. 
Croupal Variety. — It would be a matter of much interest to determine in 
what proportion of cases this complication may be anticipated, and whether 
there be any definite and constant relation between the amount or charac- 
ter of the exudation in the pharynx and its extension to the larynx. As 
yet, however, no general conclusions can be arrived at in regard to any of 
these points. The frequency of its occurrence varies much in different 
epidemics, the proportion varying from one or two per cent, to as high as 
fifty [>er cent, of all the cases. Indeed, as in an epidemic referred to by 
Trousseau, the disease may, in almost every instance, assume a primary 
laryngeal form. 

As might be expected from the considerations presented under the head 
of croup, this complication occurs more frequently and is much more fatal 
in children than in adults. 

It is a well -recognized fact that true diphtheritic croup is nearly always 
preceded or accompanied by p-eudo-membranous exudation in the fauces or 
pharynx, but the amount of depf)sit in these latter places may be extremely 
small and yet be followed by extensive exudation in the air-passages ; while, 
on the other hand, there is often copious deposit upon the pharynx in cases 
where the larynx doe?* not become invaded. 

No case, indeed, is free from the chance of this com[)lieation ; it con- 
stitutes the chief source of danger in the mild variety, and yet is occa- 
.^ionally met with as the immediate cause of death in the most malignant 
attacks. 

The pseudo-membrane is quite frequently found, in cases where the air- 
passages have become involved, to extend through the larynx and trachea, 
as far down as the tertiary bronchi, or in some instances, even to their finest 
divisions. 

In this respect diphtheritic croup does not differ from i)riiiiary rrouj), 



664 DIPHTHERIA. 

imless it be, indeed, that it seems to be more frequent in the former for the 
exudation to extend to the smaller bronchial tubes. 

We have seen that there is no essential difference in the condition of the 
mucous membrane beneath the deposit in the two affections; and that 
they are equally liable to be associated with inflammatory conditions of 
the lungs. 

Unless, therefore, the more highly corpuscular character of the exudation 
in diphtheria constitutes a ground of distinction between these two forms 
of croup, it seems difficult to establish a diagnosis between them on merely 
anatomical grounds. 

When diphtheritic croup is secondary, appearing in the course of measles, 
scarlatina, or other general disorders, the conditions found after death in the 
larynx are much the same as in primary diphtheritic croup. The mucous 
membrane here, however, as in the fauces, is usually more intensely in- 
flamed, and is more frequently ulcerated. 

The possibility of the occurrence of croup should never be lost sight 
of, and every case should be treated as though it tended to invade the 
larynx. It is especially important to detect the very earliest signs of the 
approaching danger, since its onset is frequently extremely insidious. 

If violent cough is excited by attempts to swallow liquids, it usually in- 
dicates that the epiglottis is inflamed, and the seat of pseudo-membranous 
exudation, which impedes its movements and thus allows the fluid to pass 
into the larynx. The extension of the exudation to the larynx is indicated 
by the cough acquiring a rough croupy sound, though it often has not the 
loud clangor of ordinary croup ; the respiration becoming sibilant, and the 
voice weak and hoarse. 

When the false membrane in the larynx is fully developed, the voice is 
almost or quite extinct, and the cough, losing its croupy character, becomes 
stifled and less frequent. The respiration is now peculiar; there is con- 
stantly a certain degree of dyspnoea, as shown by the frequent labored 
breathing, but there are, in addition, paroxysms of suffocation, induced by 
spasm of the laryngeal muscles, during which the dyspnoea is frightful, and 
attended with tossing of the whole body and the most violent efforts at in- 
spiration. 

Death may occur during one of these paroxysms; but usually they sub- 
side and are followed by intervals of comparative ease, soon interrupted 
by the recurrence of the same alarming phenomena. 

The intervals become more and more brief, and finally the patient sinks 
into a comatose condition, and dies with all the symptoms of asphyxia. 
If, during the violent efforts at respiration which attend these paroxysms 
of dyspnoea, or owing to the action of remedies, portions of the exudation 
are dislodged and coughed up, the most urgent symptoms are often imme- 
diately relieved. It is, however, but a deceitful repose, for in most cases 
the pseudo-membrane reforms, and the recurrence of the croupy voice 
and sibilant respiration announce that the danger of suffocation is again 
imminent. 

In favorable cases, however, either when the membrane does not reform, 
or when it is dislodged as often as formed, recovery may occur ; the par- 



CUTANEOUS DIPHTHERIA. 665 

oxysnis of dyspnc^a recur at lonirthoiiinir intervals, and tiiially disappear; 
the cough becomes ixradually more soft, and frairments of pseudo-mem- 
brane, mixed with muco-purulent fluid, are disciiarged ; the voice returns, 
and the capihiry circulation becomes re-established. 

In some cases, when the exudation has extended through the larynx 
and tnichea deeply into the minute bronchial tubes, there is an absence 
of marked croupal symptoms, and death occui's slowly, after extreme dysp- 
ncva and oppression of the chest, with all the sym})toms of deficient aera- 
tion of the blood. These cases occur more frequently in adults than in 
children on account of the larger size of the larynx in the former. 

The reader is referred for a 'more full account of this condition to the 
article on pseudo-membranous laryngitis. 

2. Xiual Vnrietif. — We have already mentioned that Bretonneau states 
that the disease occasionally begins at the uares, and extends thence in a 
most insidious manner. ^lore frequently, however, the affection of the 
nares is consequent upon an extension of the exudation from the pharynx. 

This complication is second in gravity only to the occurrence of croup. 
It impedes still further the already obstructed respiration, is attended with 
a foul acrid discharge from the nostrils, and, in addition, experience has 
shown that it is usually a sign of great malignancy in the case. Accord- 
ing to Trousseau, the result is almost always fatal, the blood-poisoning 
being marked, as shown by the great alteration in the physical properties 
of the bloixl, the proneness to hiemorrhages, the waxy pallor of the skin, 
and the ultimate fatal termination by syncope. 

The detection of this complication in its incipient stage is therefore of 
the highest importance, and Bretonneau (5th memoir, Syd. Soe. Trans., pp. 
196, 197) has laid down the most minute directions for its recognition at 
this stage. If the patient present any evidence of disease of these passages, 
as a slight snuffling or coryza, during the prevalence of diphtheria, the 
finger should be placed behind the angle of the lower jaw, below the lobe 
of the ear, and thence passed down the side of the neck, and if swelling of 
the cervical glands be noticed, it renders it probable that there is false 
meinhrane in the nares. 

If, further, the upper lip be found reddened exclusively under one nos- 
tril, and that on the >'n\e of the glandular swelling, or if the swelling ex- 
ist.*? on both sides, but unequally, and if the lip is correspondingly red- 
dened, the probability that there is nasal diphtheria is converted into a 
certainty, since ordinary coryza, acting equally on both nostrils, produces 
equal rednes« of both sides of the upper lip. 

3. Cutaneous Diphtheria. — It is one of the characters of diphtheria which 
entitles it to be regarded as a blood disease, that different and distant parts 
are apt to become affected simultaneously or consecutively with the pecu- 
liar inflammation and exudation. We find, indeed, that in many cases of 
diphtheria there is a tendency to the formation of pseudo-membrane upon 
any portion of skin denuded of its epidermis. 

This tendency varies greatly in different epidemics; according to our ex- 
pf-rience it is of rare occurrence in this city. It was, however, noticed by 
Bard nearly a century ago, and has been made the subject of special study 



DIPHTHERIA. 

by Bretonneau and Trousseau.^ The pseudo-membrane forms upon any 
blistered surface ; upon leech-bites ; upon excoriations; in fissures, as behind 
the ears, or at the angles of the mouth ; or on the outlets of the vagina and 
rectum. 

The part that is to be the seat of pseudo-membranous deposit becomes 
surrounded by an erysipelatous redness ; it is painful, exudes an abundant 
fetid serous fluid, and soon becomes covered with a grayish false membrane. 
This deposit gains in thickness from beneath ; and, at the same time, ex- 
tends in every direction, by the development of vesicles in the neighbor- 
hood, the bases of which become the seat of diphtheritic deposit. 

The layers of membrane, bathed in the fetid serous fluid, soon change 
color, decompose, become horribly offensive, and impart the appearance of 
true gangrene. 

Trousseau has observed this cutaneous exudation in cases where no 
affection of the throat existed, and has clearly established the identity of 
these various forms of diphtheria by facts collected in an epidemic in the 
neighborhood of Orleans, where the disease in some persons presented its 
ordinary features, while in others the exudation occurred on the vulva, on 
blistered surfaces, on the hairy scalp affected with favus, or upon ulcers. 

The constitutional symptoms which accompany cutaneous diphtheria are 
usually extremely grave and adynamic. 

General Symptoms. — In the mild form of this disease the invasion is 
often highly insidious ; there is usually fever, but the strength and appetite 
are not much disturbed at first. There is at the same time, in some, but 
not all cases, pain in the throat, which may or may not be accompanied 
by difficulty of deglutition. Both these symptoms are, however, often 
very slight, or they may be entirely wanting, a fact with which the prac- 
titioner should be well acquainted, as this, absence of local symptoms by 
which to explain the cause of the sickness, gives to the disease, in some in- 
stances, a remarkably insidious character which may well mislead. In 
one fatal case, at three years of age, that came under our notice, there 
were neither complaints of pain, nor difficulty of swallowing, so that the 
parents had not the least suspicion of the throat being the seat of disease, 
though we found it violently inflamed, and covered with deposits of thick 
false membrane in points. On another occasion, we were sent for to see 
two children who had been sick for four days with slight fever, languor, 
and loss of appetite, but who were not thought to be seriously ill. We 
found them laboring under extensive pseudo-membranous angina, with 
the early symptoms of croup. They both died a few days later of croup. 
The symptoms, prior to the development of the croup, had been so mild in 
both cases as to cause no alarm, and yet the anginose disease had evidently 
been progressing insidiously for several days. We attended, a few years 
since, for three days in succession, a boy who was attacked suddenly with 
vomiting and slight fever, loss of appetite and languor, and whom we sup- 
posed to be suffering from mere gastric irritation. His only local symp- 
tom was pain in the chin, and this was not reported to us until afterwards. 

1 On Cutaneous Diphtheria, Arch. Gen. de Med., 1830 (et loc. ante cit.). 



GENERAL SYMPTOMS. 667 

The mother chanced to look into his throat, and, finding there some 
whitish spots, sent us word. AVe found him with very considerable mem- 
branous exudation, which was fortunately prevented from extending into 
the larynx by proper treatment. Quite frequently have we been sent for 
to see children attacked with croup, and on finding the fauces thickly 
covered with exudation, have been told that the patient has been ailing for 
near a week before with languor, slight peevishness, loss of appetite, and 
some little pain in the throat. To this point, the strangely insidious char- 
acter of the anginose symptoms in the early stage of many cases, we can- 
not too strongly invite the attention of the reader. It is one of the very 
greatest importance, since at that time, above all others, ought the case to 
be placed under proper treatment. 

It is to this class of cases that, owing to the trifling character of the 
constitutional symptoms, the name of diphtheroid sore throat is sometimes 
applied, although inaccurately, since it is calculated to create doubt as to 
their essentially diphtheritic nature. 

It has been, on the other hand, stated, that, during epidemics of diph- 
theria, cases occur which present the usual general symptoms, with some 
difiicultv of swallowintr and swellinor of the cervical glands, but in which 
no pseudo-membrane is formed, the fauces being merely of a dark-red 
color, with swelling and elongation of the uvula, and sometimes tumefac- 
tion of the tonsils. 

Such cases are rarely fatal, and, as a rule, yield readily to the ordinary 
treatment for diphtheria. 

In addition to these mild cases, in which the chief danger is from the 
extension of the exudation into the larynx, the disease in many instances, 
and especially under the influence of epidemic causes, assumes a grave 
form, in which the danger depends not upon an accidental extension of in- 
flammation, but upon the essential alteration of the blood, and the condi- 
tion of the entire system. 

In these cases also the onset may be insidious, though it is often pre- 
ceded for a short time by general malaise, indisposition to play on the 
part of children, and to exertion on that of adulti?, and slight swelling of 
the cervical glands, and pain on deglutition. 

Whether these prmlromes have been present or not, a more or less 
marked chill ushers in the febrile action, which is often quite intense for 
a few days; so that, when the throat aflTection is decided, a doubt may 
exist for a short time whether the approaching attack is one of scarlatina 
or diphtheria. The fever, however, soon subsides almost completely, some- 
times indeed leaving the surface pale and cooler than natural. The pulse 
may remain frequent, but is weak and compressible; and the general 
symptoms are all characteristic of deficient vital force. 

There is not usually any marked mental disturbance after the second 
day, the child being intelligent, though dull and indisposed to pay atten- 
tion to anything. 

There are but few symptoms of digestive disorder; the appetite, which 
is often retained for the first day or two, soon diminishes, and the child 
often becomes unwilling to take anv food, partly from the pain caused by 



668 , DIPHTHERIA. 

the efforts to swallow, partly from complete anorexia. There is rarely any 
vomiting, unless provoked by remedies ; and the bowels, though usually 
torpid, occasionally incline to be loose. The urine is rather scanty, quite 
frequently albuminous, and upon microscopic examination is found to con- 
tain renal epithelium and casts from the renal tubules. This symptom 
will be again and more fully alluded to among the complications. 

At the same time, the submaxillary glands enlarge, and the fauces as- 
sume the appearances we have already described. There is a great in- 
crease in the secretion of saliva, which often dribbles quite profusely from 
the mouth, and is apt to be offensive, though rarely fetid. In many cases 
there is in addition a discharge from the nostril, which becomes acrid and 
offensive when there are false membranes in the nasal passages. 

The voice is commonly obscured and nasal, or somewhat hoarse, even 
when the larynx is not involved. 

Cough sometimes exists, and may have a slightly ringing spasmodic 
character, due to mere irritation of the larynx, though it usually resembles 
in sound that produced by the action of hawking, rather than a common 
cough. 

In a very small proportion of the cases, an eruption, resembling that of 
scarlatina, appears at irregular periods in the course of the disease. It 
appears, however, that this eruption lacks the punctated appearance of the 
scarlatinous rash ; does not appear at any fixed day of the disease ; is 
irregular in its progress, and is not followed by desquamation. 

The reports of it are, however, scarcely numerous or accurate enough to 
enable us to say positively that intermingled cases of scarlatina have not 
been mistaken for diphtheria, or that the two poisons may not have been 
acting jointly. 

The further course of these cases varies widely. If the result is to be 
unfavorable, the depression and loss of strength increase rapidly ; the sur- 
face grows pale or sallow, and is below the natural temperature; the pulse 
becomes exceedingly frequent and feeble ; the fauces assume a gangrenous 
appearance from decomposition of the false membranes ; the swelling of 
the cervical glands increases, and the patient often refuses to make the 
effort to swallow, though deglutition is still generally possible ; there is a 
constant fetid discharge from the mouth and nostrils ; the breath is horri- 
bly offensive ; and death ensues amid the most profound prostration. Or, 
at a much earlier period of the disease, the fatal event may be precipitated 
by the extension of the exudation to the larynx. 

We must also allude to the occasional occurrence of sudden death, even 
in cases not of the gravest type. This dreadful accident appears to result 
from paralytic failure of the heart's action, or, less frequently, from the 
sudden formation of heart clot ; and the fact that it may occur, should call 
for the most careful attention to the avoidance of all exertion on the part 
of the patient. 

If, on the other hand, the case tends toward recovery, the false mem- 
branes become detached and thrown off, the strength improves, the pulse 
becomes fuller and stronger, and the appetite returns. Even in advanced 



PROGNOSIS. 669 

convalescence, however, there is serious danger, as will be seen more fully 
hereafter, of the occurrence of troublesome or even fatal sequeliw 

In a still more severe group of cases than those above sketched, the 
symptoms are of the most asthenic or malignant type. 

In these cases the anginose affection, though it may be severe, rarely 
attracts much attention. The pseudo-membranes in the fauces are soft and 
pulpy, and, when examined microscopically, highly corpuscular and gran- 
ular ; they soon decompose, and become discolored by the blood which ex- 
udes from the mucous membrane. There is, moreover, a strong disposition 
for the exudation to extend to the posterior nares, or to appear on various 
portions of the external cutaneous surface. The breath and the discharge 
from the mouth and nostrils are indescribably fetid. In some cases true 
ulceration, and even gangrene, of the fauces occurs. There is, however, 
less i»ain ccmiplained of, and less indisposition to swallow than in many 
lighter cases, owing probably to the depression of the nervous centres from 
the poisoned state of the blood. There may be high fever during the first 
few days, but this soon disappears, and is replaced by a deadly pallor of 
surfiice; extremely feeble, running pulse; and at times low muttering de- 
lirium. 

Passive haemorrhages from the nostrils, mouth, rectum, or other mucous 
passages, are of frequent occurrence. 

The result in these cases of profound diphtheritic infection is almost in- 
variably fatal ; death resulting quietly from pure exhaustion, without the 
development of any complications. 

The duration of diphtheria varies considerably. Ordinary cases recover 
in about seven, eight, or nine days, whilst more severe attacks are often 
protracted until the end of the second week. 

It is impossible, however, to say that the disease has actually run its 
course in this time, since there are sequehe \Niiich may appear during ad- 
vanced convalescence, and retard the recovery even for many weeks. 

On the other hand, in fatal cases, death may occur from croup, as early 
as the end of the second day ; though usually the larynx does not become 
implicated under five or six days, and this accident may occur so late as 
the twelfth or fourteenth day of the attack. 

In extremely malignant cases, death may also occur during the first few 
days. On the whole, however, it may be said that the majority of deaths 
from all causes occur in the period between the sixth and twelfth days. 
When death results from one of the sequela?, either disease of the kidneys 
or paralysis, it may be deferred for weeks, or even for several months. 

Phognomh. — In cases of ordinary severity, when the patient is seen 
early, and the disease remains limited to the pharynx, the result is usually 
favorable; though no case, not even the mildest, is free from danger, either 
of extension into the larynx or bronchial tubes, of exhaustion, or of the 
supervention of some complication, such as endocarditis, or the formation 
of h^art-clots. If, on the contrary, the exudation extends to the nasal 
passages, the prognosis is more unfavorable ; and when the larynx becomes 
implicated, the prognosis b exceedingly grave ; if the disposition to the 



670 DIPHTHERIA. 

production of false membrane spread to the skin, rectum, or vulva, the 
prognosis is also very grave, and death generally occurs in a state of pro- 
found adynamia. 

If any other signs of unusual malignancy are present, such as abnormal 
slowness, or great frequency and smallness of pulse ; marked prostration, 
with pallor and coolness of the surface; great tumefaction of the cervical 
glands; abundant pseudo-membranes, pultaceous and rapidly decomposing; 
hi-emorrhages from various mucous surfaces ; acrid, fetid discharges from 
the mouth or nostrils ; intense and persisting albuminuria, with diminution 
of the amount of urea excreted ; the prognosis is, of course, much more 
unfavorable. 

It must be remembered, however, that no one of these symptoms, nor 
even any combination of them, is necessarily of fatal import ; that cases 
are often rescued apparently from inevitably impending death ; and that, 
however threatening the symptoms may be, it is our duty, in this disease 
even more than in many others, to persevere to the very latest moment in 
the judicious application of suitable remedies. 

It is as yet impossible to arrive at any plausible estimate of the average 
mortality of diphtheria, so widely does the proportion vary in different 
epidemics. Neither sex nor temperament appear to have any influence 
upon the result ; but extreme youth undoubtedly renders the prognosis 
much more grave. 

The prognosis in the secondary form of diphtheria is also more unfavor- 
able than in the primary. 

Diagnosis. — We have already sufficiently dwelt upon the general symp- 
toms and local signs which enable us to detect diphtheria, in every instance, 
after the disease has fully developed itself 

In examining the fauces in the early stage of the affection, it is well 
to remember that in simple 'angina, the crypts of the tonsil-glands occa- 
sionally become so distended by their secretion as to present the appear- 
ance of small, round, and slightly elevated whitish patches, which might 
readily impose upon a hasty observer for pseudo-membranous deposits. 

In regard to the value of the peculiarities upon which a differential 
diagnosis between diphtheritic croup and idiopathic primary membranous 
croup is so frequently based, we have fully expressed our opinion in the 
article on the latter disease, to which we would refer the reader. 

Diagnosis from Scarlatina. — The great resemblance which at times exists 
between the anginose symptoms of scarlatina and diphtheria has led some 
authors to suggest that they are identical diseases, and the following fur- 
ther points of resemblance have been adduced : the two affections prevail 
frequently simultaneously in the same region, and even in the same family; 
in certain cases of diphtheria, a rash, very similar to that of scarlatina, is 
said to appear; and the urine, in diphtheria, is frequently albuminous. 
That this similarity is, however, more apparent than real, is evident from 
the following considerations. 

1. Although in some epidemics of diphtheria a rash is said to have been 
occasionally noticed, its occurrence is at most the rare exception, instead 



COMPLICATIONS AND SEQUEL.E. 671 

of the almost invariable rule, as in scarlatina ; it differs, too, from that of 
scarlatina, in appearing at irregular period:?, in being partial, appearing 
suddenly in patches, not deepening gradually in intensity, and in being of 
a uniform erythematous redness, without the punctated appearance pecu- 
liar to the scarlatinous eruption. 

L\ The albuminuria of diphtheria presents these distinctive features as 
compared with that of scarlatina, that there is not always any diminution 
in the amount, nor any constant change in the character of the urine 
when it is present ; that it occurs in the early part of the attack, and in- 
creases as the disease approaches its height, or may disappear suddenly, 
even in the early part of its course; that although usually noticed in 
severe cases (and probably a very unfavorable symptom), there seems to 
be no necessary connection between the urine becoming non-albuminous 
and the disease assuming a milder type. 

3. There is a wide difference in the sequela? which succeed the two affec- 
tions ; dropsy scarcely ever following diphtheria, while various paralytic 
phenomena, which are rarely noticed after scarlatina, are of frequent oc- 
currence. It is very much more common, also, to have suppuration of the 
glands of the neck after scarlatina. 

4. In the same way, endocarditis, though it has recently been noticed in 
a few cases of diphtheria, is much more frequent in scarlatina. 

One of the most positive proofs of the essential difference of these two 
affections is the fact, attested by universal experience, that they exercise 
no protective power whatever against each other, and that individuals 
whose systems are protected against a second attack of scarlatina, are 
fully as likely to contract diphtheria as those who have never suffered 
with either of these diseases. 

It may also be added that second attacks of scarlatina are very rare, 
while they seem to be much more common in diphtheria. 

It geems evident to us, therefore, that in the present state of our informa- 
tion uj>on this subject, scarlatina and diphtheria must be regarded as en- 
tirely distinct affections, although presenting quite numerous points of 
singular resemblance. 

Complications and SKCiVELJE. — A/bvminuna. — AVe have already 
briefly alluded to the peculiarities of the albuminuria of diphtheria, but 
the importance of the symptom merits a more full discussion. 

The occasional presence of albumen in the urine in cases of diphtheria 
was first noticed by Mr. Wade in 1857, who also found associated with 
the albumen, tube-casts and renal epithelium. It was shortly afterwards 
recognized by MM. Bouchut and Empis' in thirteen out of fifteen cases; 
and since then has been found, in a varying proportion of the cases, by 
many ob.servers in different epidemics. 

The character of the urine when it contains albumen is not constant, 
but usually it is quite pellucid, of acid reaction, and a[)parently free from 
any dejxisit ; although, on standing, both tube-casts and epithelium may 
settle to the bottom. The quantity also varies considerably, Hillier hav- 

> De rAlbum. dans lea Mai. Cuuenneuses, Cumpt. Rcndus, 1859. 



672 DIPHTHERIA. 

iug found it much diminished, while, according to West and Wade, it fre- 
quently remains normal. 

The amount of urea excreted is usually increased in diphtheria, and, 
according to Sanderson, the presence of albumen and tube-casts in the 
urine is not necessarily associated with any interference in its elimination, 
but this does not agree with the examinations of others, who have found 
a diminution of the solid excreta when albumen was present. 

The quantity of albumen varies much, being at times a mere trace, and 
again being present in large amount. The kinds of tube-casts noticed by 
Wade, and which are the ones usually found, were small, waxy casts ; 
casts of a similar size, but granular, probably from commencing disinte- 
gration, and ordinary epithelial casts, and fibrinous flakes. 

Albuminuria in diphtheria occurs at various stages of the disorder, 
in some cases even during the first few days. It not rarely comes on 
insidiously, and may manifest its presence by no peculiar constitutional 
symptoms. There can be, however, little doubt of the grave import of 
its appearance, though as yet its exact significance has not been accurately 
defined. 

It is indeed true, that it has been found in large quantities in cases 
which have preserved a mild character throughout (Sanderson) ; but on 
the other hand, Bouchut and Em pis regard it as a highly unfavorable 
sign, coinciding w^ith very great gravity of the disease ; and Wade be- 
lieves that the quantity of albumen is usually in direct proportion to the 
retention of effete material, and that indications of impairment of the 
renal function are almost constantly precursors of an unfavorable termi- 
nation. 

Hillier {op. cit.) examined 38 very severe cases in regard to this point, 
and found albumen present in 33, 32 of which proved fatal, while of the 
5 free from albuminuria, all recovered. 

The albumen appeared in 1 case on the fourth day, in 3 on the fifth 
day, in 2 on the seventh day, in 5 on the ninth, and in 1 each on the 
thirteenth and nineteenth days. Usually the albumen disappears from 
the urine as the severity of the symptoms diminishes, but Bouchut has 
known it to persist after convalescence, and finally produce, as in Bright's 
disease, anasarca and hydrothorax. 

Heart-clot. — The formation of coagula in the cavities of the heart during 
life has been noticed in many conditions of the system ; and this terrible, 
because almost necessarily fatal accident, is now always dreaded in the 
course of several diseases, of which diphtheria is eminently one. 

There have even been epidemics of an unknown nature, but where the 
only discoverable lesion have been enormous fibrinous concretions in the 
heart. Such epidemics have been recorded by Huxham, Chisholm, and 
recently by Armand.^ 

The symptoms mentioned by these authors as significant of this acci- 
dent are, pain at the pit of the stomach ; difficulty in respiration ; extreme 
anxiety and restlessness ; anxious expression and depression of spirits ; 

' Des Concretions Fibrineuses et Polypiformes du Coeur, 1857. 



HEART-CLOT. 673 

slight, dry, and rather spasmodic cough ; the face beiug at times livid, and 
the surface dry and inclining to be cool, with coldness ot' the extremities. 
The pulse was small and irregular, and, in some of Armand's cases, an 
abnormal murmur was detected in the heart; there was usually consider- 
able duluess over the cardiac region ; the resj)iratory murmur remained 
pure and quite full, and the chest normally resonant. 

According to Robinson, the first observation of sudden death in diph- 
theria from the formation of heart-clot was made by Dr. Werner, of Linz, 
in Austria, in 1842; and the second by Winkler, in 1852. 

In England, Dr. Richardson^ appears to have been the first to call 
attention to the diflerence between these symptoms ef embarrassed circu- 
lation and those of obstructed respiratiou, as met with in diphtheritic 
croup. 

His account of the symptoms of the former condition agrees closely 
with that given above as to the coolness and almost marbly pallor of the 
surface; the moderate lividity of the face; the constant restlessness and 
intense anxiety; the feeble, quick, and irregular action of the heart, with 
a muffled character of the sounds, and in some cases an abnormal mur- 
mur. He also calls attention to a peculiar prominence of the anterior 
part of the thorax in very young children, which he believes to be strictly 
diagnostic of fibrinous obstruction. 

In obstruction of respiration, on the other hand, the surface becomes 
livid, the veins turgid, and the muscles are often convulsed ; the heart- 
sounds are clear, though feeble, and the breathing is the first to stop at 
death, instead of the circulation, as in the other case. 

In three cases occurring in the practice of one of ourselves,^ in which 
we were able to diagnosticate the condition, death took place on the twenty- 
first, twenty-fifth, and twenty-eighth days respectively. In each case the 
local symptoms had given way and almost disappeared, and the children 
seemed to have entered upon convalescence, when slight but steadily 
increasing signs of circulatory embarrassment became perceptible, and 
after a few days' battling against the constantly increasing obstruction, 
the little patients each died as though worn out by the unequal struggle. 

In no ca.se was there any evidence of any other organ l)eing implicated; 
one of the cases was, however, complicated with all)uminuria. 

The pulse was not noted to be over one hundred ; the cardiac sounds 
were unattended with murmur, but confused, indistinct, and seeming as 
though reduplicated. 

There was no marked paralysis, but in one case partial paralysis, and 
in another marked mu.scular debility. 

At the autopsy, in each ca.se, the right side of the heart was full of clots, 
which were either dark-colored, with whitish six)ts, or yellowish-white 
throughout, quite firm, and adherent to the endocardium, and ai)peared 
to have been forming for several days. In one case, a clot in the left ven- 

1 Med. Times and Gaz., March 8, 1856 j British Med. Jour., Feb. 16, and April 
7, 1860. 

« Dr. J. F. Meigs, Am. Jour. Med. Science, April, 1864, vol xlvii, p. ?A)o. 

43 



674 DIPHTHERIA. 

tricle presented at its lower extremity a broken, irregular, uneven, and 
frayed or granulated appearance, as though the disintegrating process by 
which thrombi are broken up, had commenced in it. In none of the cases 
were there any evidences of endocarditis. The same accident has been 
observed during the past ten years by Dr. Barry,^ Mr. H. Smith/ and Mr. 
C. R. Thompson,^ and many others, and in a valuable thesis published 
recently* by Dr Beverley Robinson (now of New York), ten cases are 
fully described, in at least five of which the ante-mortem formation of 
clots occurred. 

The symptoms which he deduces, from a careful analysis of his own 
and the other recorded cases, as indicative of this condition are : coolness 
of the extremities, pallor of the face, prostration, anxiety, agitation, and 
peculiar intense dyspnoea ; associated with a feeble pulse, dull, weak, and 
veiled heart-sounds, and frequently with the signs of emphysema of the 
lungs. 

Most of the cases have occurred in young subjects, and the clot has 
formed late in the course of the disease, or even after convalescence has 
begun. The cause of this deposition of fibrin is not very apparent; in 
our article on this subject, already referred to, it was suggested that the 
coagulation might depend upon some peculiar change in the tissue of the 
endocardium, analogous to that which gives rise to the diphtheritic exuda- 
tion on mucous surfaces. 

No such alteration has, however, as yet been detected, and Dr. Rich- 
ardson, to whom the profession is so much indebted for his investigations 
upon the coagulation of the blood, attributes it, in this case, to a deficiency 
of the volatile agent which retains the fibrin in solution, together with 
an actual increase in the amount of the fibrin of the blood, this combi- 
nation producing the most favorable condition possible for fibrinous depo- 
sition. 

Endocarditis. — Although in the above cases no lesion of the endocar- 
dium has been found, inflammation of this membrane has, as already 
stated (page 660), been quite frequently noticed in diphtheria. It has 
usually appeared late in the course of the disease, and has been attended 
with pain in the prsecordia, frequent pulse, hurried respiration, an anxious 
countenance, with in some cases a systolic murmur. In fatal cases, there 
was found a roughened, reddened, thickened appearance of the valves, as 
if due to interstitial deposit. In some cases, also, a granular or fatty de- 
generation of the muscular fibres of the heart has been observed, as by 
Bristowe, Hillier, Robinson, ourselves, and others. 

Paralysis. — One of the most frequent and important, and certainly the 
most peculiar of the sequelse of diphtheria, is the occurrence of paralysis. 
It originally attracted the attention of MM. Trousseau, Lasegue, and 
Faure, under the form of difiiculty of deglutition, and a nasal character 

1 British Med. Jour., 1858. 

2 Med. Times and Gaz., Dec. 17, 1859. 

3 Med. Times and Gaz., Jan. 7, 1860. 

* De la Thrombose Cardiaque dans la Diphtherie. Paris, 1872. 



PARALYSIS. 675 

of the voice ; but since then has been observed in the most varied forms 
and degrees, affecting both general and special sensation and the power of 
motion. In most cases, every trace of the primary disease has disappeared 
before any paralysis is noticed ; the patient sleeps, eats, and dige^t^ well, 
yet many cases emaciate, and there is often marked pallor of the surface. 
In many instances, also, especially in children, there is great irascibility 
or irritability of tem{^)er. 

Most frequently a nasal character of voice and regurgitation of liquids 
through the nose are the first symptoms to call attention to the disease, 
though these may be preceded by some slight difficulty in articulation, 
or by alteration of the sense of taste at the back of the tongue. On 
examining the fauces the soft palate is found hanging relaxed, and, if 
it be pricked, there is no contraction of it, nor does it give the patient 
pain. 

At times but' one side is paralyzed, and the uvula is drawn towards the 
sound side. The affection may extend no further than the fauces, and soon 
disappear; or it may advance, the eye usually becoming next affected, fol- 
lowing the throat affection, and preceding any paralysis of the limbs. The 
impairment of vision is rarely of long duration, lasting from a few days to 
two months, and is of every grade, from mere inability to read fine print 
to perfect blindness. 

Dr. Greenhow has noticed that the pupils become dilated, and act slug- 
gishly under the influence of light, for a day or two before the sight becomes 
sensibly impaired, and may remain so for a time after sight has been re- 
gained. He has also observed that patients who were unable to read with 
unassisted sight could do so with the aid of convex glasses, so that he at- 
tributes the impairment of sight to paralysis of the ciliary muscle and 
temporary loss of the adjusting power. 

In addition to this want of accommodation, however, depending on 
paralysis of the ciliary muscle, Bouchut believes thj^t there is in many 
cases, and e.sjx^cially in those who have had albuminuria, a serous infiltra- 
tion of the fundus of the eye, due to the amemic condition of the blood, 
and which may impair the nutrition of the optic nerve, and even lead to 
it* atrophy. 

The following case, which came under our observation recently, at the 
clinic at the University of Pennsylvania, affords an interesting illustration 
of the peculiarities of this form of paralysis. The ophthalmic examina- 
tion was made by Dr. S. D. Risley, who has kindly placed the results at 
our disposal. 

Case — Emma W., »t. 7 years, suflored with an attack of sore throat, tho nature 
of which «a* not recognized by the physician in altondance. It was quite H-vere, 
WH<» accompanied by marked ^welliiij? of th*- glnnds at the anglers of the jaws, and 
cttnifK-llpd her to be confined to bed fur a week or ten days. Soon after convalescence 
began, it was noticed that her voice became altered, and that fehe occa-sirmally r«'gur- 
gilated fluids that i^hc attempted to swallow. Her general health improved, how- 
ever, and in a few days she roturn*»d to school, which she was soon obliged to quit 
in cons«^-quence of rapidly increasing inability to read, on account of the print seem- 
ing blurred and " the letters running together." 



676 



DIPHTHEHIA. 



Two weeks later, or about five weeks from the time of the first attack, examina- 
tion of the eyes showed the fundus of both eyes entirely healthy. 0. D., V =: 

Acuteness of vision, as determined by Snellen's types, normal, and she can 

20 



14 at2^^ 0. S., V: 



and she reads Jr. No. 16 at 2^ 0. D. 



20_ 

XX 

road Jr. No 

emmetropic; 0. S. hypermetropic = ^V- With glassses -f- ^V (convex glasses with 
12'^ focus) 0. D. reads Jr. No. 1 at 12^^, O. *S'. at 14^^. The pupils react promptly 
to iii;ht. 

She was directed to wear -f- J^ gh^sses for near work, and strychnise sulph., gr. 
■ji^, was ordered four times daily. This was in a few days increased to five times a 
da}', and its use was followed by prompt improvement, so that in less than two 
weeks the power of accommodation was entirely restored. 

Deafness may follow this amaurosis ; then the lower limbs become 
affected, the patient becoming paraplegic, and next the upper extremities ; 
then the muscles of the alimentary canal and bladder, causing impaction 
of the rectum with fseces and retention of urine, or tlie sphincters of 
these organs alone may be involved, and lead to involuntary discharges. 
Finally, the muscles of the trunk, including those of respiration, may be- 
come paralyzed, and in some very rare cases even the muscles of the heart 
are involved. It is stated that the paralysis of the extremities is never 
strictly unilateral. The paralysis is rarely confined to loss of motion, but, 
in a majority of cases, sensation is either much modified or lost ; and in- 
deed in some instances there has been no loss of motion, the sentient nerves 
alone being affected. In other cases the sensibility has beqn found exalted, 
or there has been in the same case hypersesthesia in the upper, with anaes- 
thesia in the lower extremities. 

The paralysis, whether it be of motion or sensation, is progressive and 
gradual, even in the same set of muscles, and usually involves one limb 
before it extends to other parts. The mind, though often feeble and dull, 
acts correctly in most cases. 

During the continuance of these phenomena, the appetite may remain 
good and digestion easy ; but there are often marked evidences of the con- 
tinuance of some morbid action in the economy. The surface is of an 
earthy, sallow hue, calorification is often imperfect, and the circulation is 
much depressed, the pulse being small, weak, and much reduced in fre- 
quency. 

In some cases, indeed, the affection runs on to a fatal issue, usually con- 
sequent upon a failure of one of the vital functions of circulation or res- 
piration. M. Faure has given a vivid picture of these sequelae in their 
worst form, when the patient, paralyzed, indescribably prostrated, with 
imperfect speech and power of deglutition, impaired vision, imbecility of 
mind, oedema, and even gangrene of the extremities, finally dies in some 
fainting fit, or passes away almost imperceptibly. 

The result of diphtheritic paralysis is, however, favorable in a large 
majority of cases ; thus of 77 cases collected by Dr. Keynolds, but 9 were 
fatal. We have ourselves never met with a fatal result in a single in- 
stance, although a large number of cases, some of them of very severe 
character, have come under our observation. The duration is, however, 
more uncertain, varying from one or two weeks to several months, the 
mean duration being about a month. 



1 



PARALYSIS. 677 

It is as yet impossible to advance any satisfactory explanation of the 
cause of these grave paralytic sequelie. They occur probably in one-fourth 
of all cases, in greater or less degree, and are noticed with at least equal 
frequency after mild as after severe attacks. 

At tii*st, indeed, the fi\ucial paralysis was attributed to some such local 
cause as indamniation of the sheath of the nerves supplying these parts, 
and Greenhow still contends that the nerve affections bear some proportion 
to the local severity of the attack, the paralysis and auiesthesia being 
more complete on that side of the fauces which has been most severely 
affected by the primary disease; but we have been able to satisfy our- 
selves that this does not occur with any uniformity. Charcot and Vul})ian 
have, however, demonstrated in a case of paralysis of the palate, lesions 
both of the palatine nerves and muscles. It is difficult to determine 
whether such lesions are of constant occurrence in the ordinary cases which 
rapidly recover. It seems improbable, also, that in cases where widespread 
paralytic symptoms are present, which subsequently entirely disappear, 
any serious lesion of the nerve-trunks or of the muscles could have existed. 

Nor is the occurrence of albuminuria necessary for the development 
of paralysis, since the urine is often quite normal throughout the entire 
course of cases, which are nevertheless followed by marked palsy. 

The most plausible view we can entertain of the nature of these nerve 
affections, is that they are the direct effect of the diphtheritic poison, which 
while modifying the blood crasis, and so acting on the system at large, has 
an especial tendency to the nervous system ; while at the same time, some 
of the local forms of the paralysis may be associated with lesions of the 
nerves and muscles of the part affected. 

Ataxic Form. — In some cases, which are comparatively rare, the nerve 
affection does not constitute actual paralysis, but takes the form of loco- 
motor ataxia. In such cases, the muscular force in the affected parts, 
usually the lower extremities, is not materially diminished, so that the 
patient can move them forcibly when he is lying down ; but there is such 
a degree of incorirdination in the motions communicated to them, that 
combined movements, even in the supine position, may become impossible. 
It is, however, especially in walking, that this loss of coordinating power 
manifests itself; the gait becomes irregular, the patient falls if the eyes 
are closed, and the ca.se presents all the characteristics peculiar to well- 
marked locomotor ataxia. 

The first instance of this diphtheritic ataxia appears to have been 
observed by Jaccoud' in 1861 ; it was soon after noticed by Eisenmann ;' 
and more recently a well-marked case has been reported by Dr. Gray,' in 
a boy of nine years old, following an apparently mild case of diphtheria. 
It is evident, also, as pointed out by Jaccoud, that a certain number of 
the cases which have been reported under the name of diphtheritic j)aral- 
Tsis, have in reality been examples of locomotor ataxia, the paralysis hav- 

* he* Parapl^ics et I'AUixip du Mouvement, p. 681, Paris, 1864. 

■ Die Bewei:unc^^ Atnxie, Winn, 1863. 

» London Med. Times and Gazette, February 6tb, 1809, p. 141. 



678 DIPHTHERIA. 

iug been only apparent. We have met with two well-marked examples 
ourselves, in both of which entire recovery followed. This diptheritic 
ataxia is in all probability due to the same unknown morbid condition or 
dyscrasia, which causes the actual paralytic symptoms which are more 
frequently observed as sequelae of diphtheria. It usually yields to the 
treatment recommended for the latter conditions, though in Gray's case, 
death occurred, apparently from rapid loss of nervous power, seven weeks 
after the appearance of the nervous symptoms. 

Treatment. — The treatment may be usefully considered under the two 
heads of local and general. Of late yeai*s, the importance of the latter 
has been more and more recognized as supreme, and, indeed, the utility of 
all local treatment has even been questioned on the ground that the throat 
affection is merely a local evidence of the constitutional disease, and that 
the disease rarely kills save by involving organs beyond the influence of 
such agents. We have, however, no doubt as to the very great importance 
of proper local treatment; although, on the other hand, we are not pre- 
pared to say, with some eminent authorities, as Trousseau, that topical 
applications are the most successful and important remedies in diphtheria. 

The great objects to be held in view in the local treatment, are to favor 
the separation of the pseudo-membranes, and to prevent their extension 
from the fauces into the larynx and nasal passages. 

Local Treatment. — The most important of the local remedies are in- 
cluded in the lists of astringents and caustics. 

Of these, nitrate of silver has properly been used more than any other 
substance for many years past, and is highly recommended by MM. 
Bretonneau, Yalleix, Grisolle, Rilliet and Barthez, Trousseau, West, and 
many others. 

It is employed both in solution and substance. The latter form is, 
however, open to the objections, that if the extent of the false membranes 
be at all considerable, the solid caustic can seldom be applied to more 
than a small portion of it, and that it is attended with the risk of slipping 
from the porte-caustic into the pharynx, and thence passing into the stom- 
ach.^ The solution is therefore generally preferred. M. Bretonneau ad- 
vises its employment in the proportion of half an ounce of the salt to an 
ounce and a half of water ; and West employs a solution of the strength 
of a drachm to an ounce. 

We have usually made use ourselves of a solution of ten or twenty grains 
to the ounce, and have found it abundantly strong. It may be applied 
either by means of a piece of sponge fastened upon a proper handle, which 
is the best method, or a camel's-hair pencil, nearly as large as the end of 
the little finger. The application should be made once, twice, or even 
three times in the course of the twenty-four hours. 

Hydrochloric acid is also frequently employed, either pure or diluted 

^ Dr. Geddings recommends, when it is desirable to use the solid nitrate, to re- 
duce it to powder, and to roll the sponge probang, previously moistened with mu- 
cilage of gum arabic and squeezed, in the powder until a suflficient quantity adheres, 
and to apply it thus prepared to the diseased parts. 



LOCAL TREATMENT. 679 

with from oue to ten parts of honey; the more dilute forms being used in 
the case of children. 

It possesses the great advantage over the other mineral acids, that its 
caustic action does not extend much from the point of application, but is 
open to the objection of causing a white plastic exudation on any part of 
the raucous surface, not covered with false membrane, with which it may 
come in contact, which may lead the physician into error. 

When the limits of the pseudo-membrane can be seen in the pharynx, 
following M. Bretonneau's advice, the acid may be used more concen- 
trated, and the sponge, after being dipped into the acid and squeezed so 
as to be merely moistened, should be carried rapidly into the pharynx, 
and withdrawn after lightly cauterizing the surfiice. 

When on the contrary, the limits of the membrane cannot be seen, the 
acid should be more diluted, and leaving more of it upon the sponge, this 
should be passed down over the epiglottis and then pressed against the 
base of the tongue, by raising strongly the handle to which it is tied, in 
order to express a few drops upon the mucous membrane of the larynx. 
The cauterization is to be i)erformed once or twice a day, according to the 
necessity of the case. For children under ten years of age, the sponge 
ought to be about half as large as a pigeon's egg. It is to be fastened to 
a piece of flexible whalebone, by making a crucial incision into it, intro- 
ducing into this the end of the whalebone, and securing it with good seal- 
ing-wax, which is not acted upon by the acid as any ligature would be. 
When about to be used, the whalebone is warmed and curved into such a 
shape as will allow it to pass into the pharynx without touching the roof 
of the mouth. M. Valleix proposes that the sponge should be fastened to 
the whalebone with waxed thread, and that this should be covered with 
sealing-wax, to preserve it from the action of the acid. This would cer- 
tainly be safer than the mere wax alone. 

Applications of powdered alum, tannic acid, and chlorinated lime, 
are recommended by writers of high authority. In slight cases, in which 
the disea-<e shows but little disposition to extend, such applications may 
answer very well ; but when the attack is threatening, and especially when 
the exudation is spreading, we should neglect these minor remedies, and 
resort at once either to nitrate of silver, dilute muriatic acid, or the tinc- 
ture of the chloride of iron. If, however, these powders are employed, 
they may be applied by means of a throat brush, or by causing a suffi- 
cient quantity to adhere to the forefinger of the right hand, and conveying 
it upon this to the disea.*ed surfaces. 

The astringent and caustic preparations of iron have lately been in- 
trofluced in the treatment of this affection with much benefit. They cause 
the pseudo-membranes to contract and shrivel, and thus favor their separa- 
tion, while, at the same time, they modify the action of the mucous mem- 
brane, and also tend, as does the sol. soda? chlor., to correct the fetor 
ari.-ing from the putrefaction of the false membranes, and to prevent poi- 
soning of the system by absorption. 

The tr. fern chloridi and the ferri jx?rchloridum are among the best prep- 
arations, and may be applied, either pure or diluted, several times in the 



680 DIPHTHEKIA. 

course of twenty-four hours. Mousell's salt, iu powder, has also been 
highly recommended by Beardsley, of Connecticut, and possesses the same 
mode of action, though somewhat more escharotic. 

Carbolic acid, diluted with glycerin and water, applied by a mop to the 
throat, appears to possess almost equal virtue in causing the separation of 
the pseudo-membranes, and preventing their re-formation. 

Various applications have also been recommended from the fact that 
they exercise a direct solvent power over the pseudo-membranes, and thus 
promote their removal. Among those which have been thus recommended 
are solutions of lime, potassa, and soda ; solution of chlorinated lime ; of 
chlorate of potash or soda ; of permanganate of potash ; of bromide of 
potassium ;"of pepsin ; and of dilute lactic acid. 

Dr. Jacobi {Amer. Jour, of Obstet., May, 1868, pp. 13-65), has pub- 
lished an analysis of the relative value of these solvent applications. Ac- 
cording to him, lime-water requires four to ten hours to thoroughly liquefy 
soft diphtheritic exudation ; while for firm pseudo-membranes, it requires 
from thirty to seventy-two hours. Potash and soda, and their salts, act 
more slowly ; and the one other application which he recommends as 
equally rapid in its action is a solution of bromine gr. j, bromide of potas- 
sium gr. j, in f5vj of water. 

We have carefully tested the latter solutions, as well as those mentioned 
above, and from the results of repeated tests, have concluded that lime- 
water is the most powerful in its solvent action upon pseudo-membranous 
exudations. We have frequently found, when fragments of firm white 
exudation have been placed in lime-w^ater at a temperature even lower 
than that of the buccal cavity, that the exterior began in a very short time 
(half an hour) to undergo disintegration, and that the whole fragment 
was reduced in a few hours to a granular putrilage. It is, however, un- 
doubtedly true that this effect will be produced with very diflferent rapid- 
ity upon different specimens of pseudo-membrane. 

There is no real difliculty in making use of any of these applications, 
if the children be properly managed. One or two assistants must hold 
the patient in such a way that the head shall be thrown backwards, and 
the hands and feet secured. The physician must depress the tongue with 
the handle of a spoon held in the left hand, while he holds in the right 
the pencil or sponge mop. If the child refuse to open the mouth, it can 
generally be made to do so by holding the nose iu order to force it to 
breathe through the mouth. If this fail, all that is necessary is to press 
the handle of the spoon against the teeth, when the patient will soon be- 
come too much fatigued to offer further resistance. 

Gargles. — When the patient is sufficiently old and intelligent to be able 
to use gargles thoroughly, any of the substances which have been recom- 
mended as local applications may be thus used, being of course largely 
diluted. Thus tr. ferri chl., hydrochloric acid, sol. sodse chloriuatse, in the 
proportion of f5j or f3ij to f^vj, or chlorate of potash in strong solution, 
may be used as gargles with much advantage in some cases. 

These solutions may also be very efficiently applied to the throat in a 
finely divided condition, by means of the steam or hand-ball atomizer ; a 



I 



GENERAL TREATMENT. 681 

mode of application which is peculiarly useful in cases where the pseudo- 
membrane has extended to the jarynx. As it is often impossible to em- 
ploy gargles, and as we attach very great importance to the frequent use 
of mild solvent applications, particularly lime-water, we would strongly 
recommend the use of the steam atomiz^er for this purpose. 

A very convenient and ready application, and one from which we have 
obtained marked advantage in several cases, especially where the exuda- 
tion had extended to the larynx, is by covering the patient's head with a 
sheet, and introducing a vessel containing slaking lime, so that the steam 
may be freely inhaled. It is probable that the chief benefit is here derived 
from the warm watery vapor; though a small quantity of lime, in the 
form of impalpable powder, probably gains entrance to the fauces and 
air-passages.* 

Ice. — In a rather early stage of the disease, if there is much heat and 
engorgement about the throat, cold, wet compresses may afford temporary 
relief; and great benefit is often obtained in cases where there is much 
swelling and inflammation of the fauces and pharynx, by the free internal 
use of ice, allowing the patient to hold small pieces of it almost constantly 
in the mouth. 

Other external applications may also be employed to reduce the swell- 
ing of the cervical and submaxillary glands, render deglutition more easy, 
and relieve suffering; and, in this way, the persistent use of poultices or 
spongio-piline fomentations are of service. 

It is essential to remember, however, that all blisters or irritating appli- 
cations capable of destroying the epidermis, must be carefully avoided, 
owing to the tendency, already alluded to, of the pseudo-membranous de- 
posit to occur on such abrasions. 

When the nasal fossje have become implicated from extension of the 
pseudo-membrane, one of the dilute solutions recommended as gargles 
should be injected frequently through the nostrils, or the desired effect 
may be even more thoroughly secured by the use of the same fluid through 
a Thudichum's nasal douche. 

General Treatment. — Whatever differences of opinion may exist in 
regard to the relative merits of the various local applications we have 
enumerated, all high authorities are now agreed as to the general char- 
acter of the constitutional treatment which should be adopted. 

' Bouchut has laMy ftlrenuoii.aly advised active cauterization of the fauces, or 
ablation of the ton.*ils, not only for the purpo!»e of removing the exudntion which 
apf»^ar» on them, which he considers the localization of the disease, but also of 
facilitating respiration. 

According to him, the operation of ablation has now been porformod fifteen 
timf»*. five by himself, and ten by MM. Domer«, Symyan, Speckahn, and Paillot, 
with successful results in each case, no false membrane reappearing. 

Despite this favorable rej»ort, however, the procedure appears to us objectionable, 
regarding, as we do, tho imp)ortance of the lf>cal condition as secondary to that of 
the alteration of the blfx>d. The operation must further cause the greatest alarm 
and most powerful resistance on the part of young children, and it seems highly 
improbable that a large proportion of cases should be attended with the same for- 
tunat<* exemption from a recurrence of pseudo-membranous formation, as occurred 
in Boucbut't 



682 DIPHTHERIA. 

Some years ago, before opportunities had been presented for studying 
diphtheria in its epidemic form, as it has since occurred, it was customary 
to employ moderate depletion early in the attack, if the patient was vigor- 
ous and strong, and to follow this by the use of mercury and antiphlo- 
gistics, with a view of subduing the febrile excitement, and causing the 
dissolution and absorption of the pseudo-membrane. 

With the increase of knowledge, however, of the true pathology and 
natural history of the disease, which has been gained of late years, all 
depleting and antiphlogistic plans of treatment have been, by common 
consent, abandoned as indefensible either in theory or practice, and all 
efforts are directed to promoting the nutrition of the patient and sup- 
porting the strength of the system, as indicated by the marked tendency 
to prostration, the feeble pulse, and the manifest deterioration of the 
blood. 

It is probable that those cases in which bloodletting and the administra- 
tion of mercurials were adopted with such apparent benefit, were either 
erroneously considered diphtheritic, or that the disease, when occurring 
sporadically, as it formerly did, was of a far more sthenic type than it has 
presented of late years. 

It must be added, however, that in the sporadic cases still frequently 
met with, when no grave epidemic influence is prevailing, the use of 
alkalies, as soda, combined with small doses of calomel, has been found 
very successful. 

Kegarding diphtheria as a constitutional aflfection, depending upon a 
peculiar alteration of the blood, we must admit that we are in possession 
of no remedy which in any respect merits the name of a specific in its 
treatment. 

Among the best internal remedies, however, are the various preparations 
of chlorine, iron, and bark, which may be given singly, or, preferably, in 
combination. 

Thus there are no remedies of more uniform and marked advantage 
than sulphate of quinia and tincture of the chloride of iron, given in full 
doses at short intervals. Hydrochloric acid or chloric ether may be added 
to these tonics, and this combination is strongly recommended by West and 
other high authorities. 

The Sanitary Commission, in London, reported very strongly in favor 
of a mixture containing tincture of the chloride of iron, with chlorate of 
potash, chloric ether, and hydrochloric acid, sweetened with syrup ; full 
doses being employed according to the age of the patient, and frequently 
repeated. This combination has been, by Gibb, rendered still more stimu- 
lating by the addition of muriate of ammonia. 

Oil of turpentine has been recommended (Dr. Perrey, Med. Times and 
Gaz., March 5th, 1859) in large doses, both for its stimulating effect, and 
from its tendency to promote the absorption of lymph in adynamic states 
of the system, where mercury cannot be given. 

Chlorate of potash, given in Huxham's tincture of bark, has been 
vaunted as almost specific in the treatment of diphtheria ; but, as re- 



1 



GENERAL TREATMENT. 683 

marked by West, it unquestionably fails to produce here those excellent 
effects which are obtained from its use in ulcerative stomatitis. 

Permanganate of potash, which has been so extensively used of late 
years in zymotic diseases, has been used both locally and internally in 
this affection, but apparently without any very positive advantaire. 

Emetic,^; Purrjafive-^. — Emetics are useful when the exudation shows a 
disposition to extend to the larynx, or when there is much difficulty of 
breathing from tumefaction of the fauces, or from accumulation of the 
pseudo-membranous deposits. We would recommend under these cir- 
cumstances the use of alum or ipecacuanha, as recommended in the article 
on pseudo-membranous laryngitis ; the emetic being repeated in six or 
twelve hours, if the same indication should continue or recur. 

A purgative dose is useful at the commencement of the disease, merely 
as an evacuant. After that period only such laxatives need to be em- 
ployed as may suffice to keep the bowels soluble. 

Stimulants. — In the milder forms of diphtheria, where no complications 
exist, the cases usually terminate favorably without the use of any stimu- 
lants ; but there are many cases, on the other hand, characterized by pallor 
of surface, marked weakness of the circulation and tendency to prostration, 
great enlargement of the cervical glands, and extensive disease of the 
throat, where the pseudo-membranes rapidly decompose and assume a 
gangrenous appearance, and the urine is frequently albuminous, in which 
stimulants, freely administered, are positively required. 

In cases where such adynamic symptoms are present, we should begin 
early in the attack with the administration of the weaker stimuli, and em- 
ploy the stronger forms as the disease advances and the strength of the 
system succumbs more and more. 

Food. — In no disease should more sedulous care be paid to securing to 
the patient a proper amount of suitable nourishment; and, indeed, in the 
absouce of any remedy which can be looked upon as essential or specific, 
we mu<«t assign, perhaps, the most important part in the treatment of 
diphtheria to food and stimulants. It is at least certain that where these 
cannot be administered in proper quantity, all other treatment is un- 
availing, and hence it is our duty, upon finding that the pain and fatigue 
experienced by the child when forced to take frequent doses of medicine 
make it utterly unwilling to take food, to abandon all strictly medicinal 
treatment, and trust to sustaining the powers of the system by the free use 
of stimulants and concentrated food. 

In cases where mer-hanical obstruction exists, or where all efforts at 
voluntary' deglutition are obstinately resisted from fear of the great pain 
caused by the act, nutritious and stimulating enemata must be immedi- 
ately resorted to. These may consist of beef tea, eggs beaten up in milk, 
brandy in the form of milk-punch, and, further, may be medicated by the 
addition of quinia. They should be given every three «)r four hours, in 
rather small quantity, and not so concentrated a« to irritate the bowel. 
When thus administered it is quite possible to sustain life for several 
days, until fofKl can again be introduced into the stomach. 

In addition to the local and general treatment above recommended, the 



684 DIPHTHERIA. 

patient should be rigorously confined to bed during the whole treatment, 
and for at least ten days after the disappearance of the exudation. This 
caution is given, not only on account of the danger of that most fatal ac- 
cident, the formation of a heart-clot, but because we have twice known 
the exudation to reappear when the patient had been allowed to leave the 
bed at too early a period ; and in one of these the exudation extended into 
the larynx on the occasion of the second attack, in spite of all that could 
be done, and life was saved only by the operation of tracheotomy. 

The most scrupulous cleanliness of the person and surroundings of the 
patient should be preserved ; free and uninterrupted ventilation secured ; 
and on account of the positive, though perhaps slight, contagiousness of 
diphtheria, it is wise to practice separation of the well children in the 
family from the sick. 

The treatment required in those cases where the pseudo-membrane ex- 
tends into the larynx, and especially the discussion of the indications for 
the operation of tracheotomy, will be found in detail in the article on 
pseudo-membranous laryngitis. 

Treatment of Paralyds. — We have already stated that the prognosis in 
diphtheritic paralysis is usually favorable, the symptoms often disappear- 
ing in the course of time without treatment. The cure may, however, be 
much hastened by a persistence in the administration of iron and quinia, 
to which strychnia should be added in full doses. 

Nitrate of silver has also been employed in full doses with apparent 
benefit. 

The paralyzed jnuscles should be faradized daily; and, when accessible, 
sea-bathing or sulphur baths may be employed with advantage. 

In those cases where the muscles of deglutition are especially affected, 
and the nutrition of the patient is suffering from his inability to swallow 
sufficient food, it is desirable to resort to the use of nutritious enemata. 

Treatment of Heart-clots. — Under the supposition that the blood is 
hyperinotic in the latter stage of diphtheria, the various salines, especially 
the vegetable ones, such as the citrates and acetates, and ammonia, given 
either as the carbonate or in the liquid form, have been recommended by 
Richardson. 

When, however, the symptoms indicate that deposition of fibrin has 
absolutely occurred, it is probable that nothing can be done in the way of 
curative treatment. Alkalies may be given internally, the vapor of ammo- 
nia inhaled, alkaline solutions injected into the veins, but there is little 
reason to hope that any effect upon the clot can be produced. 

In one of the cases reported by us (Joe. cit.), the clot presented at one 
extremity a granular, partially disintegrated condition, as though its re- 
moval had begun by interstitial action, and the mechanical effects of the 
blood current ; and it is possible that by supporting the powers of nature 
the removal of the clot might be effected in this way. Indeed, there are 
cases on record (quoted by Robinson, loc. cit.) in which the symptoms have 
most clearly demonstrated the existence of a clot in the cavities of the 
heart, where still recovery has occurred. 



MUMPS. 685 



ARTICLE III. 



MUMPS. 



Definition; SynonYxMs; Frequency. — Mumps is an acute febrile spe- 
cific disease, contagious and epidemic ; occurring but once in an individual ; 
attended by an intlammation of the parotid and sometimes of the sub- 
maxiUary glands, with a tendency to metastasis to the testicles in males 
and to the mamma?, vulva or ovaries in females ; and almost invariably 
resulting in recovery. 

Some authors, as Niemeyer, object to classifying mumps with constitu- 
tional diseases; but the fact that it undoubtedly possesses the features 
enumerated in the above definition, and which, in the present state of our 
knowledge, must be regarded as specifically characteristic of that class of 
affections, seems to us to fully entitle it to be included with the other gen- 
eral diseases. 

Mumps is known under a variety of names in every language. The terms 
usually employed to designate it by English and American authors are 
cynanche parotidea, parotitis, parotiditis, and inflammation of the parotid. 

It will be impossible to obtain any definite idea as to the frequency of 
this affection, until the system has been introduced of registering not 
merely deaths but all cases of disease, since mumps is scarcely ever fatal. 
Its frequency is, however, known to vary very widely in different years, 
owing to epidemic influences ; so that while in certain years we do not 
meet with a single case, in others we are called to a considerable number. 

Causes. — Nothing is known in regard to the essential nature of the 
cause of mumps. The disease is, however, unquestionably contagious, and 
it quite rarely happens that one member of a family sickens with mumps, 
without some of the other children being attacked. 

Mumps rarely occurs iis a sporadic affection, but appears, as already 
stated, in epidemics of varying extent and severity, at times being limited 
to a single locality or even a single institution, and at others affecting large 
cities or districts. 

Se<i*oti appears to exert a powerful influence upon the development and 
activity of the specific poison of mumps, since the epidemics occur nearly 
always in the spring or autumn. According to Vogel, it is said to be 
endemic on the damp coasU* of Holland, England, and France. 

Af/e also exerts an unquestionable influence, by modil'ying the suscep- 
tibility to the contagion of mumf>s. Thus the disease is far most common 
between the ages of seven and fifteen years; whilst it is almost unknown 
before the end of the first year, comparatively rare between the ages of 
one and five years, and, on the other hand, quite rare in adult«. 

Although it appears certain, however, that the susceptibility to the con- 
tagion of mumps diminishes with each succeeding year after the age of 
fifteen, we must in great part explain the rarity of the disease in adult 



686 MUMPS. 

life, by the fact that a large proportion of people have had it in childhood, 
and are thus protected against a second attack. 

Second attacks of mumps are indeed of extreme rarity. 

Anatomical Appearances. — Opportunities very rarely occur for the 
.examination of the parotid glands in mumps, since this disease is scarcely 
ever fatal. Virchow,^ who has shown that, in cases of symptomatic sec- 
ondary parotitis, the affection starts in the gland-ducts, maintains that the 
idiopathic form occupies the same seat. Bamberger,^ on the other hand, 
states that the whole gland appears enlarged and reddened, with its tissues 
swollen and flaccid, owing to an interstitial exudation of lymph. The 
softness and indolent character of the swelling, however, the fact that it 
usually extends beyond the borders of the gland, and its usually rapid and 
complete subsidence, all induce us to believe rather that there is slight 
catarrh of the ducts, with mere oedema of the interstitial and surrounding 
connective tissue. 

It is only in rare and very severe cases that there is sufficient lymph 
effused to undergo organization and lead to persistent increase in the size 
of the gland, or to so compress the ducts as to induce atrophy of the true 
gland-tissue. In even more rare cases, it is said that suppuration may 
occur. In the secondary form, on the other hand, such as is seen in con- 
nection with the various specific fevers, the occurrence of suppuration is 
frequent. 

Symptoms. — In some cases the attack of mumps is preceded for a day 
or two by slight prodromes, consisting of restlessness, feverishness, loss of 
appetite or vomiting; in excitable children, symptoms of nervous disturb- 
ance may occur. More frequently, however, the local symptoms appear 
simultaneously with the fever, and we have generally found positive swell- 
ing of the parotid gland upon our first visit to the child. 

The earliest local symptom is often pain, complained of under the ear, 
and increased by pressure and by all movements of the jaw, as in masti- 
cation. There is also stiffiiess felt in opening the mouth. The swelling 
appears first immediately beneath the ear ; the depression between the 
mastoid process and the ramus of the jaw quickly becomes filled, and the 
swelling rapidly extends on to the cheek and neck. At first the swelling 
is flat, indurated, and presents the outlines of the parotid gland; but it 
soon becomes prominent, the most marked projection usually being ob- 
served immediately anterior to the lobe of the ear, and extends beyond 
the limits of the affected gland. The central part of the swelling cor- 
responding to the parotid, remains firm, indurated, and more or less 
elastic, while at the periphery it is softer and often pits on pressure. The 
degree of enlargement varies much in different cases, being at times mod- 
erate and confined to the parotid region, while in other cases, it extends over 
a large part of the neck and face, and may be so great as, especially when 
both glands are affected simultaneously, to give to the head and neck a 
pyramidal shape. 

' Quoted by Niemeyer (op. cit., vol. i, p. 436). 
2 Quoted by Vogel (op. cit., p. 113). 



GENERAL SYMPTOMS. 687 

Quite frequently the submaxillary glauds are involved, and the swelling 
con-ecjuently extends along the baae of the jaw ; in more rare oases, the 
enlargement is most marked in this region, or, indeed, the submaxillary 
glands may be almost exclusively the seat of the aftection. 

The skin over the seat of enlargement is at times scarcely altered in 
color, or may present more or less marked redness. There is usually only 
very moderate tenderness on pressure. The pain sutiered during the at- 
tack varies greatly ; in some cases it is merely a marked sense of tension 
and pressure, while in other instances, it has been complained of as constant 
and severe, and extending even to the chest and shoulders. The movements 
of the head are impaired, and those of the jaw are impeded to such an 
extent that the mouth can only be slightly opened, and mastication is per- 
formed imperfectly and with great difficulty. 

Usually the swelling increases for from three to five days, remains at its 
acme for a day or two, and then rapidly subsides, so that in about ten days 
the face has regained its natural appearance. 

Mumps usually involves both parotids, though they rarely become af- 
fected simultaneously; the left gland is said to be most frequently the 
first inflamed, and subsequently, in twenty-four or forty-eight hours, or 
even when the swelling has disappeared from the side first affected, the 
opposite gland becomes enlarged. Occasionally the enlargement does not 
undergo complete resolution, and a circumscribed, painless, hard swelling 
remains for a variable time in the parotid region. In very rare cases, sup- 
puration is said to have occurred. The salivary secretion is variously 
aflTected, and may be either diminished or excessive, or remain unaltered. 
Occasionally the external swelling is associated with enlargement of the 
tonsils and (edema of the submucous tisssue of the pharynx. In such cases 
the difficulty of deglutition is much increased, and there may even be 
marked obstruction to respiration. 

General Symptols. — Usually the constitutional disturbance in mumps 
is but slight and subsides even before the swelling of the parotid gland. 
Until the disease reaches its height, however, there is fever, with heat and 
dryness of the skin ; the pulse and respiration are accelerated, the api^etite 
impairefl or lost, and the thirst usually extreme. There may also be, espe- 
cially in nervous children, marked restlessness, sleeplessness from the pain 
and discomfort caused by the great swelling of the neck and face, and even 
mild delirium at night. As already mentioned, however, these febrile 
symptoms usually disapf>ear alx)Ut the fifth or sixth day. 

One of the most curious features in parotitis is the tendency which oc- 
casionally exhibits itself to metastasis. The parts which are liable to be 
thas secondarily inflamed are the testicles and scrotum in males, and the 
mammse, the vulva, and the ovaries in females. The most frequent of 
these metastatic inflammations in mumps is the afltction of the testicle, 
which is much more common in men than in boys, is usually seated upon 
the same side with the enlarged parotid, and is attended with enlargement 
of the body of the testicle, serous effusion into the tunica vaginalis, and 
oedematous swelling of the scrotum. The swelling of the parotid ordi- 
narily subsides when any of these metastatic aflTections appear, but occa- 



MUMPS. 



sionally the two inflammations continue together, a circumstance which 
shows, as Nieraeyer points out, that they are in reality due to a common 
cause, and that no true transference of inflammation takes place from one 
point to the other. In some instances, the swelling of the parotid subsides 
a variable time before the development of the metastatic affection, and, 
during the interval, alarming symptoms of depression and cerebral dis- 
turbance have been noticed, and at times referred to a metastasis to the 
membranes of the brain. There is, however, no actual meningitis pres- 
ent, and upon the redevelopment of the external swelling, these nervous 
symptoms disappear. 

Prognosis ; Duration ; Course ; Termination. — Idiopathic parotitis 
or mumps almost invariably terminates favorably. The duration of the 
case varies from four or five days in very mild cases, to ten or twelve in 
severe ones. As already stated, the inflammation usually terminates in 
complete and rapid resolution. In some cases, however, a large amount 
of lymph is formed in the interstitial tissue of the gland, undergoes par- 
tial organization, and causes a hard, painless swelling, which persists for 
some time. In some epidemics, suppurative degeneration of the gland 
has been noticed, and the abscess which formed has either opened out- 
wardly or into the external auditory meatus. We have known persistent 
hydrocele to follow the inflammation of the testicle occurring during an 
attack of mumps. 

Diagnosis. — The acute febrile character of the affection, and the pecu- 
liar seat and shape of the swelling, always serve to render the disease 
readily recognizable. 

Treatment. — As mumps almost invariably runs a favorable course, 
the treatment should be of a mild and expectant character. 

The child should be strictly confined to bed ; the diet should be fluid, 
partly on account of the great difficulty in mastication, light and diges- 
tible, consisting chiefly of preparations of milk and light animal broths. 
The only internal remedies required are febrifuges, such as spirit of nitrous 
ether and solution of acetate of ammonia, with a free supply of water and 
acidulated drinks; occasional laxatives; and, if there is sleeplessness, 
small doses of Dover's powder or some other anodyne. 

Local applications appear to have little or no influence upon the course 
of the swelling. The only ones to be recommended are warm, light poul- 
tices, or light water-dressings, covered with oiled silk, which do not annoy 
the child, and tend to favor resolution. If the induration be marked and 
extensive, so as to threaten suppuration, it has been advised to apply a 
few leeches behind the angle of the jaw. If it should become evident 
that suppuration has occurred, the abscess should be opened immediately, 
and the discharge favored by the application of poultices, in order to 
prevent further destruction of the gland or perforation of the external 
auditory meatus. In cases where induration and enlargement of the gland 
persist, absorbent applications, such as inunctions of iodine or mercury, 
should be made over the tumor. 

In cases where alarming symptoms of depression and cerebral disturb- 
ance make their appearance after the sudden subsidence of the parotid 



r 



MALARIAL FEVER. 689 

s\Yelliijg, the eff« rt may be made in order to redevelop the external inflani- 
matiou by stimulating applications to the surface, and by the internal 
administration of nervous and ditlusible stimulants, such as ammonia, 
musk, or brandy. 

After the acute symptoms of the attack have subsided, and the chikl 
has fully entered upon convalescence, we would caution against allowing 
it to leave bed too soon, since we have occasionally observed such prema- 
ture exposure to be followed by marked febrile secjuehie. Thus in one 
case, occurring in au adult, there was marked fever lasting for a week ; in 
another case, in a child, there was high fever for ten days; and in a third 
case, also in a child, there was most obstinate and violent vomiting for 
four days; so violent, indeed, that we feared lest some renal complication 
might have been developed ; on examination, however, the urine was 
fouud to be entirely normal. 



ARTICLE IV. 



MALARIAL FEVER. 



The propriety of introducing a chapter upon malarial fever in the 
present work, is shown not only by the fact that malarial disease is ex- 
tremely frequent in children, but also because it presents, as it occurs iu 
them, so many peculiarities as to frequently lead to the true nature of 
such attacks being overlooked. 

Causes; Frequency. — There are cases upon record in which malarial 
disease appears to have been contracted in utero, and where immediately 
after the birth of the infant it has presented unmistakable evidences of 
the disease. We have ourselves met with several such cases, where the 
symptoms, and the prompt effect of quinine, left no doubt as to the diag- 
nosis. At all periods of childhood, even from the age of a few weeks up- 
wards, there can be no doubt that children readily contract malarial 
disease on exposure to its cause. Indeed we have met with cases which 
have shown that the susceptibility of children to malarial poison may be 
even greater than that of their parents or other adults exposed to the same 
influences. In children over five or six years old the symptoms of malarial 
fevers are apt to be almost the same as in adults: the following remarks 
must therefore be understood to apply especially to those diseases as they 
present themselves in younger subjects. 

Sympto3LS. — Malaria presents itself in children both in acute and 
chronic forms. The former occurs both as intermittent and remittent 
fever. In our article upon typhoid fever we have carefully pointed out 
the fact, that in children the febrile movement in this latter disease often 
presents such marked remissions as to have led many authors to confound 
it with malarial disea.se, under the name of ** Infantile Remittent Fever." 
But apart ^rom this, true malarial remittent fever occurs in children, and 

44 



690 MALARIAL FEVER. 

indeed it is a peculiarity of all forms of malarial disease in early life to 
present a less marked development both of the paroxysms and of the in- 
termissions. Intermittent fever in children may occur in any of the forms 
met with in adults, still the quotidian is by far the most frequent, the 
tertian less common, and the quartan decidedly rare. Whichever form 
may be present, is apt to present several peculiarities. In the first place, 
the features of the paroxysms are apt to be imperfectly developed This 
is particularly true of the cold stage. It is very rarely present as a well- 
developed chill ; in some cases, it seems to be entirely absent, but usually 
can be detected by careful observation. The child may merely become 
pale, seem weaker and more languid, or with this there may be distinct 
coolness of the hands and feet, and blueness of the nails : less frequently 
is there any discernible rigor, and as before stated a fully developed chill 
is very rare. The cold stage is of short duration, lasting from a few min- 
utes to a quarter of an hour. It is followed by the hot stage, or in some 
cases the beginning of the attack is marked by the appearance of fever. 
The degree of this is rarely very high. Sometimes the child, who has been 
merely drooping during the earlier part of the day, is noticed to grow more 
dull, to wish to be constantly in bed, or on the lap, and its head and hands 
grow warm, with perhaps some flushing of the cheeks. Indeed, in some 
cases, the fever is so slight as to pass unnoticed, unless the attention of the 
nurse is directed to it by the physician. In other cases the accession of 
fever is more marked ; the skin becomes very hot, and the cheeks brightly 
flushed ; the child is dull and yet restless ; there is rapid breathing, and 
marked acceleration of pulse. In some children, the fever is attended 
with delirium, and it is not a very rare thing to have it ushered in by a 
convulsion. This fact of the occasional occurrence of a convulsion, as a 
substitute for the chill as the initial symptom of the malarial paroxysm, 
must be borne in mind as of positive diagnostic importance. The fever 
lasts a very variable time, and rarely terminates abruptly, as in the case 
of adults by a sudden defervescence with profuse sweating. Indeed, in 
many cases, the child seems somewhat feverish during the entire twenty- 
four hours, but on careful observation is found to present increase of heat 
at some period of the day, and this is often preceded or followed by a short 
period during which the child is pale and languid, with cool moist brow 
and hands. Added to this irregularity in the symptoms and duration of 
the paroxysms, is the further source of difficulty, that the accession of 
fever occurs at very irregular hours. In children of even five years of age, 
it may occur at the ordinary time towards noon, but in younger children 
it may appear much later in the day, or even, as we have several times 
seen, late in the night. 

There are a few other symptoms to be mentioned in connection with the 
paroxysms. We have already alluded to the occurrence of convulsions 
ushering in the hot stage. Frequently the child will vomit whatever food 
was in the stomach at the time of the attack. The urine that is passed 
during the paroxysm is scanty and high-colored, while not long after the 
subsidence of the fever, there is apt to be a quite free discharge of limpid 
urine. Between the paroxysms, if no complication exists, the child may 



I 



DIAGNOSIS — PROGNOSIS. 691 

appear merely listless, with scanty appetite. Quite frequently, however, 
the disease is attended with some more marked disturbance, either of res- 
piration or digestion. The complications which we have ourselves most 
frequently observed have been bronchitis and pneumonia. In cases where 
the latter has been present, the seat of the inflammation has occasionally 
been the apex of the lung. 

The chronic fonn of mahiria reveals itself in children in tlie same way 
as in adults. No well-marked paroxysms may occur, but the patient has 
a sallow, cachectic, or anremic appearance, which of itself is quite charac- 
teristic. There is more or less emaciation from interference with nutrition, 
as the appetite is poor or capricious, and the action of the liver and bowels 
sluggish and insufficient. Enlargement of the spleen frequently follows, 
and we have met with well-marked examples of ague-cake in very young 
children. The blood becomes very poor and watery, and this, added to 
the obstruction to the circulation through the liver and spleen, in advanced 
cases may lead to ascites or cedema. We are not aware that the marked 
development of pigment-granules in the blood, which has been so often 
observed in the adult, has vet been detected in children suffering: with 
chronic malaria. In some very severe and protracted cases, granular de- 
generation of the kidneys with albuminuria, and finally urannia, has seemed 
to follow in quite young children. Some of the manifestations of malaria 
which are quite common in the adult, are very rare in children. This 
applies especially to the various forms of neuralgia, which, as met with in 
the adult, are so frequently of malarial origin, while we do not remember 
to have met with a single case of this character occurring in children. 

Diagnosis. — It is our belief that malarial disease in children is often 
not recognized, and that this is due, not so much to its real difficulty of 
detection, as to the fact that the frequent occurrence of the different forms 
of malaria in young children, is not sufficiently borne in mind. Undoubt- 
edly also there are difficulties in its diagnosis, which do not usually exist 
in adults. These arise, as before said, from the irregularity and imperfect 
development of the paroxysms. Our own experience has taught us in all 
cases of irregular febrile action, especially when occurring during the spring 
or fall, without any discoverable lesion to account for it, to suspect the 
malarial character of the attack. Bo, too, in cases where some slight lesion 
or disturbance of function exists, and yet the child seems too seriously and 
too obstinately ill for the apparent cause, and presents irregular fever with 
considerable fluctuations, the idea of the malarial nature of the attack 
should always be entertained. In some such cases, where it is impossible 
to reach a definite decision from a study of the symptoms, the diagnosis 
may be made by the therapeutic test of administering full doses of quinia 
for several days in succession. 

pRr>oNOSi8. — The result of malarial fever is usually quite as favorable 
in children as in adults, when uncomplicated with any serious local inflam- 
mation. All of its forms usually yield readily to specific treatment. The 
chief source of danger lies in the tendency to severe bronchitis or pneu- 
monia. In protracted chronic malaria, the autemic and cachectic symp- 



692 MALARIAL FEVER. 

toms have seemed to us to yield to treatment even more rapidly than in 
the case of adults. 

Treatment. — Children, even at a very early age, bear full doses of 
quinia very well. The amount which we have usually found necessary to 
arrest an attack of intermittent fever is three grains daily for children of 
one year of age or under, and one grain additional for each succeeding 
year, though we have given as much as five grains by the mouth in the 
course of the day to children of ten months, and without the slightest ill 
effect. It may be administered in the form of powders containing one- 
half grain, mixed with an equal amount of sugar and powdered extract 
of liquorice, repeated as necessary, and given at such times as to bring the 
system thoroughly under the influence of the drug before the hour at which 
the accession of fever has been noticed. Some children, however, will not 
take the powders without difficulty or nausea, and the quinia may then be 
given merely suspended in syrup of red orange, or in the following com- 
bination : 

R. — Quinise Sulph., gr. xxiv. 

Acid. Sulph. Diluti, gtt. xxx. 

Syr. Zingiberis, Syr. Simplicis, Aqua3, aa . . f^j. 
Ft. sol. — Dose, a teaspoonful three or four times a day, according to age. 

If, however, the stomach rejects it in all of these forms, as we have 
known it to do, we have found the administration by enema of two grains 
of quinia in a tablespoonful of starch-water, three times a day, equally 
successful. We may also resort to the use of suppositories, which when 
neatly made with butter of cacao and of small size are perfectly well tol- 
erated, as a rule, even by very young infants. 

In ordinary acute cases no other treatment is really required. It may 
be well to give a few doses of some saline febrifuge during each day, until 
the fever is entirely subdued, and of course any speeial disturbance of 
function must be relieved by appropriate remedies. The treatment of pul- 
monary complications must be subordinate to that of the general disease. 
All depleting or perturbing treatment must be avoided, and it will gener- 
ally be found that with the aid of mild counter-irritation, the local symp- 
toms will begin to improve, after the malarial fever has been subdued by 
quinia. It is necessary to keep up the action of quinia for some time after 
the paroxysms are broken, because the tendency of the disease to recur is 
fully as great in children as in adults. We are in the habit of thus con- 
tinuing it for three or four weeks in diminished doses, giving, however, on 
each septennary period, dating from the arrest of the paroxysms, the full 
antiperiodic dose, suited to the age of the patient. At the same time the 
child should take suitable doses of iron and arsenic, which may be conve- 
niently given in the following form : 

R. — Liq. Potassse Arsenitis, . . . • f^j* 

Vini Ferri Amari, ..... f^iij. — M. 
Dose. — From a half to a whole teaspoonful thrice daily in water after meals. 

In chronic malaria we must persist in the use of quinia, iron, and arsenic, 



EPIDEMIC CEREBRO-SPINAL MENINGITIS. 693 

for a considerable period. At the same time careful attention must be 
paid to securing the best possible hygienic influences for the child. Wlien 
practicable, a change of climate should be secured by a journey to the 
mountains or to the sea-shore. The patient should be warmly dressed, and 
carefully guarded against all exposure to damp or cold. Tht^ diet should 
be carefully selected, and every error of digestion promptly corrected. 
Even after the child is apparently restored to health, it should not be 
allowed to return to the locality where it contracted the disease, and for 
several successive springs and autumns should take a short course of quinia 
and arsenic. 

In the treatment of the enlargement of the spleen, which frequently 
occurs in chronic malaria, we have obtained excellent results from the use 
of hyjx)dermic injections of ergotin into the subcutaneous tissue of the 
abdominal wall. 



ERUPTIVE FEVERS. 

"NVe shall describe in this eruptive group of General Diseases, scarlet 
fever, measles, small-pox and vaccine disease, varicella, and typhoid fever. 



ARTICLE V. 

EPIDEMIC CEREBKO-SPINAL MENINGITIS. 

Definition ; SYNONYM^^ ; History ; Frequency. — Among the large 
Dumber of names which have been applied to this disease, the only ad- 
ditional ones which call for mention are cerebro-spinal fever and spotted 
fever. The latter ha.s been much used in this country, but as it is based 
upon a symptom of occasional occurrence only, is evidently inadmissible. 
The name we have adopted is the one now almost universally accej)ted. 

Epidemic cerebro-spinal meningitis is an acute specific febrile affection, 
occurring in epidemics of widespread or local character, but not propa- 
gated by contagion ; characterized by alterations of the blood and by in- 
flammatory changes in the membnines of the brain and spinal cord, and 
running a most irregular course both as regards symptoms and duration. 

Although it is highly probable that epidemics of varying extent oc- 
curred previous to the present century, it appears that their true nature 
was not recognizofl, and the first distinct account of epidemic meningitis 
waa published in 1805 by Vieusseux. Since that time, however, it has 
appeared more or less frequently in almost every country of the globe. 
It began its course in the United States in 1806, and numerous epidemics 
of it occurred between that time and the year 1816; again between 1823 



694 



EPIDEMIC CEREBRO-SPINAL MENINGITIS. 



and 1830; again between 1842 and 1850, and again between 1856 and the 
present time. The last epidemic began in Philadelphia in 1863, and re- 
turned annually for some years, reaching its height in 1866-67. Since 
then, however, as will be seen from the table below, it has continued to 
furnish annually a considerable number of deaths. 

It was made the subject of several valuable memoirs, among which may 
be mentioned those of Gerhard,^ Githens,^ Levick,^ and particularly the 
admirable treatise of Stille.* 

Owing to the employment of various names for this disease in the mor- 
tality reports, it is difficult to estimate the actual mortality occasioned in 
this city by it, but a good idea may be obtained from an inspection of the 
subjoined table, which presents the annual mortality for fifteen years from 
epidemic cerebro-spinal meningitis, typhus and typhoid fevers, and diph- 
theria. 





Epidemic Cerebro- 
spinal Meuingitis. 


Tj'phus Fever. 


Typhoid Fever. 


Diphtheria. 


1860 





14 


68 


214 


1861 





17 


148 


502 


1862 





37 


654 


325 


1863 


49 


131 


486 


434 


1864 


384 


335 


648 


357 


1865 


192 


334 


773 


460 


1866 


92 


96 


381 


192 


1867 


102 


138 


367 


119 


1868 


54 


108 


395 


119 


1869 


36 


49 


373 


182 


1870 


36 


69 


409 


172 


1871 


44 


37 


313 


145 


1872 


128 


35 


369 


150 


1873 


246 


31 


382 


110 


1874 


80 





461 


179 



Causes. — The disease we are considering has occurred " in all portions 
of the temperate zone inhabited by European races and their descendants ; 
in all sorts of localities, among all ranks and conditions of society, at all 
ages, and in both sexes ; and it is therefore in the strongest sense of the 
word a pandemic disease." (Stille, op. cit, p. 94.) While its epidemic 
character is so strongly marked, there is no reliable evidence as to its 
being contagious. A few authors, however, even of such recent date as 
Bristowe, assert their belief in its contagiousness. 

• Amer. Jour. Med. Sci., July, 1863, p. 105. 

2 Ibid., July, 1867, p. 17. 

3 Trans, of Amer. Med. Assoc, xvii, p. 311. 

4 Epidemic Meningitis, Phila., 1867, pp. 178. 



ANATOMICAL LESIONS. 695 

Although occurring iu both sexes and at all ages, it is more frequent 
in females, and a large majority of the cases are among minors. The dis- 
ease has undoubtedly been more frequent and virulent among overcrowded 
and filthy populations, but there is no reason to think that these conditions 
exert any more than a general depressing influence. 

Anatomical Lesions. — The chief lesions in this disease are found in 
connection with the blood and the nervous centres. 

Blood drawn from a vein during life usually presents its normal char- 
acters or else those indicative of inflammatory action, excepting in cases 
of the most malignant and rapidly fatal type. On the other hand, in 
post-mortem examinations, the blood is most frequently found to be dark, 
and either altogether fluid, or with only small dark and soft clots, in the 
cavities of the heart and the larger bloodvessels. These alterations are 
evidently what should be expected in a disease presenting the double con- 
dition of a specific blood poison and a distinct and serious local inflam- 
mation, which two elements vary greatly in their relative preponderance 
in diflferent epidemics, and even in difl^erent cases of the same epidemic; 
no definite chemical changes have been ascertained. In cases where the 
crasis of the blood is greatly impaired, microscopic examination has fre- 
quently shown an absence of the ordinary mode of arrangement of the 
red corpuscles in rouleaux, and a crenated appearance of the corpuscles 
themselves. 

The lesions of the nervous centres are chiefly seen in the meninges of 
the brain and spinal cord. In the early stage, there is extreme engorge- 
ment of the vessels of the meninges, with a loss of the normal translu- 
cency of the pia mater and arachnoid. Later, an exudation occurs 
which at first may be serous, but soon becomes sero-puruleut or entirely 
composed of thick creamy pus, with a varying proportion of lymph. The 
amount of this exudation varies greatly in diflferent cases; at times being 
quite scanty, while in other instances, several ounces of pus are present. 

The exudation usually occtipies the subarachnoid space, and is at times 
a.«5sociated with effusion into the ventricles of the braim The convexity 
and the base of the brain are both involved, though the exudation is as a 
rule more abundant over the latter, and especially about the optic chiasm, 
the fissures of Sylvius, and the base of the cerebellum and under surface 
of the pons. One or more of the cranial nerves are completely imbedded 
io the exudation. 

The spinal meninges present the same general changes, the vessels being 
congested, the pia mater infiltrated with sero-pumient fluid, and the sub- 
arachnoid space occupied by a more or less extensive exudation. These 
lesions are usually most marked about the medulla and again at the lower 
part of the cord. It is probable that the tendency of the exudation to 
accumulate at the latter pf)int is partly, at least, due to gravity. 

The substance of the brain is usually vascular and more or less softened; 
and the spinal cord presents the same changes, though less constantly and 
usually to a less degree. In some cases, however, the softening of the cord 
is extreme, and Hirsch has recorded a case in which the central canal of 
the cord was distended with pus. 



696 EPIDEMIC CEREBRO-SPINAL MENINGITIS. 

In some cases where death occurs very rapidly, within twenty-four or 
forty-eight hours, the cerebro-spinal lesions have been found wanting, not 
having yet been developed to an appreciable extent. 

There are no characteristic lesions of any other organ. 

Symptoms; Course. — In some cases the attack is preceded by the usual 
prodromes of acute specific fever ; but in many instances it occurs with- 
out warning in the midst of perfect health. Usually the actual outbreak 
is marked by a distinct rigor, followed by fever, prostration, vomiting, in- 
tense headache, and pains in the back and limbs. It is soon evident that 
the patient is seriously ill. He grows restless and tosses about, at times 
with slightly spasmodic twitchings of the muscles. The intellect often 
remains clear ; but delirium or a disposition to heaviness and dozing may 
be present. The temperature is rarely very high at first, and the pulse 
ranges from 90 to 120, according to the age of the child. As early as the 
second day we may observe that the head is retracted, and thus increases 
in its degree and soon becomes associated with a tendency to opisthotonos. 
The other nervous symptoms increase in severity ; h.eadache persists, and 
is even so severe as to elicit screams of pain ; the pupils are contracted ; there 
is delirium, with excessive restlessness or even convulsions. Extreme cuta- 
neous and muscular hypersesthesia are very common symptoms. Vomit- 
ing is apt to continue ; the bowels are constipated, the abdomen retracted, 
and the urine is usually retained. The pulse grows more frequent and 
small, the respiration greatly accelerated, and the temperature increases 
to perhaps 103° or 104° F. Herpetic eruptions about the mouth are com- 
mon ; and in a varying proportion of cases a purpuric eruption appears 
from the second to the fourth day. In some instances the course of the 
symptoms presents marked fluctuations, which may assume the form of 
distinct quotidian or tertian remissions. In unfavorable cases, stupor 
supervenes, interrupted by more or less marked spasmodic movements ; 
respiration and circulation become more and more impaired, and the 
patient dies in profound coma. In favorable cases, on the other hand, 
the nervous jactitation and delirium diminish, the tetanic muscular spasms 
relax, the urine is passed voluntarily, the pulse and respiration gradually 
uniform, and the patient enters upon convalescence. 

Death may occur even in a few hours from general paralysis, from the 
overwhelming effect of a violent and universal meningitis. It may occur 
in the course of one or two days, in malignant cases with extremely marked 
blood lesion. In cases of the regular form, death may occur from the 
fourth to the eighth day, from the eflfects of the cerebro-spinal lesion ; but 
after convalescence has commenced, the supervention of some complica- 
tion or sequel may prove fatal, even after the lapse of weeks or months. 

Before proceeding to discuss a few of the principal symptoms more in 
detail, the following case of severe type, which occurred in our practice, 
may be cited in illustration of the general sketch above given-: 

Case — David R., aet. 12 years, in good health, was attacked on June 8th, with- 
out apparent cause, with violent headache, languor, and occasional vomiting. 
Cerebro-spinal meningitis was prevalent as an epidemic at the time (1864). 

On June 9th (second day), at noon, headache continued intense, the fever in- 



CASE. 697 

creased in severity, and he vomited twice a greenish liquid. The bowels were con- 
stipated, and urine scanty. He lay in a drowsy condition ; the eyes slightly in- 
jected, but pupils of normal size ; the nose was pinched, the mouth closed. There 
was no rigidity of the muscles of the neck or of other parts. There was marked 
jactitation, with mild delirium. The skin was dry and slightly pungent; respira- 
tion 48, quick and sighing ; pulse 105. Over the whole body, but especially on the 
extremities, there are small petechiie, of livid color. Abdon)cn meteoric. Ordered 
brandy f3ss. every half hour, a saline laxative, and the following: 

R. — Morphia^ Sulph., gr. ^r^j 

Acid. Sulph. Aromat., .... tijjv. 
Elix. Cinchonae, f^ss. 

Ft. sol. — To be taken every two hours. 

In the evening, his mind was more clear ; but rigidity and soreness of muscles 
of back of neck had ajipeared, with tendency to opisthotonos. Pulse 120, irritable 
and quick. Vomiting continued. The bark mixture was changed for one contain- 
ing quinia, morphia, and dilute sulphuric acid. Iced champagne and beef tea were 
given in small quantities. Counter-irritation by capsicum and whisky. 

In the night, at two o'clock, vomiting continued frequent and uncontrollable. 
Pulse was very feeble, almost threadlike, and very irregular, varying from 100 to 
120 within a few minutes' time. Temperature equally variable, surface being al- 
ternately burning hot and chilly. Quite conscious, and complains of intense head- 
ache ; extreme restlessness continues. Frequent thin, dark stools. 

June 10th. — In morning, pulse 90, varying from minute to minute ; respiration 
less hurried. Surface warm. He passes urine and faeces. Ordered suppositories 
of gr. ss. opium and grs. ij quinia every five or six hours ; a blister behind each 
ear; f^ss. brandy every hour, and concentrated nourishment. 

About five hours later, stupor supervened and continued until night, interrupted 
by fits of violent delirium. Slight convergent strabismus. Petechia? continue, 
and there is a herpetic eruption about the mouth. Temperature reduced in ex- 
tremities. Ordered nutritious enemata ; blister 4 x 4 to back of neck ; small doses 
of opium by rectum to maintain its influence. 

June 11th. — More quiet ; no more active delirium. Bowels open more freely. 
Urine free, acid reaction, sp. gr. 10 32, with a very heavy deposit of whitish urates. 
Nourishment and medicines retained by stomach. Pulse 85 to 105, with more 
volume. Consciousness partially regained ; complains of frontal headache and 
mui^ular sorene.«8. No opisthotonos. Eyes slightly injected. Continue opium 
and quinia; beef tea ; iced champagne ; milk with lime-water. 

June rjlh. — Condition about the same. Some quiet sloep. Skin of ploasant 
temperature. Herpes abundant around mouth. Urine quite free, and light col- 
ored. Pulse about 100; respirations more full. Troatmont continued. 

June 13. — Pul«e 72 to 100. Con-M^iousness perfect, but complains of intense fron- 
tal pain. Temperature almost normal. Petechia; disappearing ; herpetic eruptions 
on face still marked. Passes urine freely; sp. gr. 10 11 ; no albumen ; bowels cos- 
tive; quinia discontinued on account i>f headache. Ordered blue mass, gr. i, every 
two hours for four doses, followed by a laxative enema, which acted freely, and 
gave much relief. 

June 14th. — Restless, and complaining of his head. Still some retraction of the 
hr-ad, and muscular soreness. Respirations 35; pulse 100 to 110. Stomach reten- 
tive. Tongue cleaning, but dry and cracked. Passes urine copiously, very light- 
colored and watery. Suppositories of quinia and opium resumed ; stimulus and 
nourishment as before. 

June 15th. — Doing well. Has emaciated very rapidly. Pulse 110; fnllint; dur- 
ing the day to 96; respirations less sighing and labored. Decubitus more natural, 



698 EPIDEMIC CEREBRO-SPINAL MENINGITIS. 

and movements more easy and free. Opiate suspended. Takes Quinia sulph , gr. i ; 
Acid, muriatis, dil. gtt. x, q. q. h. Stimulus and food as before. 

June 16th. — Doing well. Petechiae disappeared; herpes around the mouth bet- 
ter. Tongue moist, but very sore, with ulcerated cracks covered with pultaceous 
crusts. Pulse 100, of good volume. Expression natural. No signs of spinal irri- 
tation. 

June 19th. — Ninth day of disease. Convalescent. 

June 20th. — Kapidly regaining strength. Sleeps well, and eats with great ap- 
petite. No headache; expression bright and natural. Tongue has healed, and 
herpes around mouth nearly gone. Bowels regular ; urine free and normal. Con- 
tinues quinia and mineral acids. The subsequent course of the case was that of 
rapid restoration to health without any sequelse. 

In entering upon a study of the special symptoms, it will first be observed 
that the mode of onset of the disease is peculiar, and is characterized by its 
suddenness and by the early appearance of grave nervous symptoms without 
a high grade of fever. 

The symptoms furnished by the nervous system merit the closest study. 
So important are they that many authors have been* led to regard the 
whole affection as due to the meningeal inflammation, losing sight of the 
coexistent lesion of the blood. The most marked of them is headache, 
which, as already stated, appears early, is usually sharp and lancinating 
in character, and violent in the extreme. It is accompanied with pain 
along the spine, especially in the cervical region, which is much increased 
by pressure or by motion. Neuralgic pains are also very common, and at 
times are extremely severe ; they chiefly affect the extremities and the 
abdomen. From an early period of the case, there is apt to be marked 
and painful hypersesthesia of the skin, and also of the muscles ; so that 
handling the patient causes complaints or even cries of pain. Later this 
may be followed by more or less marked anaesthesia. There are frequently 
also various forms of muscular spasm. At times a high group of muscles 
will be affected with spasm, either tonic or clonic. The most frequent 
instances of this are the retraction of the head from rigid spasm of the 
cervical muscles, and the tendency to opisthotonos ; both of these condi- 
tions are very constant, and may be present in a high degree. Trismus is 
not very infrequent ; while in other cases, the muscles of the extremities 
are affected with spasm ; or again, the tetanoid vsymptoms may assume the 
form of general epileptiform convulsions, which are much more frequent 
in children than in adults. 

Paralysis in various forms, hemiplegia, paraplegia, but much more fre- 
quently as affecting a single cranial nerve (facial, abducens, or oculo-motor) 
has been observed, but as a rule is not met with until the later stages of 
the disease. In some cases, marked subsultus is present. In addition to 
these symptoms, there is rapid and marked debility, frequently associated 
with vertigo on rising into the sitting posture. Disturbances of the intel- 
lect are also more frequent in children than in adults. At first there are 
great restlessness, jactitation, and wandering delirium, which may persist 
or be replaced by more or less profound stupor ; perhaps occasionally in- 
terrupted by active delirium. In fatal cases, this stupor deepens into 
coma as the end approaches. 



SYMPTOMS. 699 

There is frequently loss of control over the bladder aud rectum, attended 
with retention or with involuntary discharges. 

The organs o{ special sen^e furnish Important symptoms. There is often 
u uniform, ditiused redness of the conjunctiva?. The pupils are usually 
contracted at fii^st, but later may be dilated or unequal. Not rarely blind- 
ness follows; due either to keratitis, to exudative inflammation of the 
retina or choroid, or to purulent exudation in the chambers of the eye. 
Squinting frequently results from paralysis of one of the motor nerves of 
the eye as already stated. In like manner, deafness often results from 
suppurative inflammation of the internal ear, or from inflammation of the 
auditory nerve. 

The exprejision of the patient varies much at different periods of the 
disease. In the early stage, the face is often pale, with pinched nose and 
sunken features. This peculiar f'acies, which was noted in the case above 
narrated, is regarded by Hii-sch and others as very characteristic. 

The puke and temperature are less uniformly affected than in any other 
of the acute specific febrile diseases. At first the pulse may not be much 
accelerated, but later it may be very rapid, or again, may present remarka- 
ble variations at short intervals. The course of the fever is very irregular ; 
in most cases the temperature does not rise above 103° or 104°, and not 
infrequently is much lower throughout the whole course of the attack. 

The disturbance of respiration is marked but Very irregular. In the 
early stages it corresponds with the condition of the pulse ; but later it 
presents irregularities due to the pressure of exudation on the pneumogas- 
tric nerves, and may then assume the peculiar form known as ascending 
and dejicending breathing, which is so frequently seen in the exudative stages 
of tubercular meningitis. 

The digeMive system presents few constant symptoms. Vomiting, how- 
ever, is nearly always present in the early stage, and may be frequent and 
uncontrollable. It is oflen unattended by any nausea, and there evidently 
depends an irritation at the base of the brain. We have already referred 
to the severe aMominal neuralgic pain sometimes complained of. The 
bowels are usually constipated, and the abdomen retracted. In the later 
stage, it is not rare for involuntary discharges to occur. 

The urine presents the ordinary febrile characters, and in addition is at 
times albuminous or even bloody. There is frequently retention, requir- 
ing the use of the catheter, though we think this less frequent in children 
than in adults. 

We have already alluded to the occurrence of eruptions on the skin. 
They are not constant, and in some epidemics have been rarely noticed. 
Still they constitute very important symptoms in the majority of cases ; 
and indeed the occurrence of a petechial orufjtion has been so marked a 
feature in most American epidemics as to render the objectionable name, 
"spotted fever," the popular title for this affection. 

Among these eruptions, groups of herpes are frequently seen on the face, 
especially about the mouth, while, in more rare instances, erythema and 
urticaria has been observed. But by far the most frequent and important 
is the petechial eruption, which appears early in the case, usually in the 



700 EPIDEMIC CEREBRO-SPINAL MENINGITIS. 

form of small spots. The proportion of cases iu which such an eruption is 
present varies greatly iu different epidemics. Stille concludes {op. cit., p. 
64) that, taking the whole of the cases of epidemic raeuingitis in Europe 
and America, it did not occur in more than 10 per cent. On the other 
hand, of 96 cases recorded by Dr. Githens {loc. cit), 36 had marked petechial 
eruptions ; and of the cases we have ourselves observed, the proportion 
has been even greater. 

The duration of this disease is extremely variable. We have seen it 
prove fatal in the adult within forty-eight hours from collapse, with all the 
evidences of profound blood alterations, and before the characteristic lesions 
of the meninges had passed beyond the first stage. Death has been known 
to follow even in a few hours, with symptoms of general paralysis. 

In cases of ordinary severity which terminate favorably, the duration of 
the acute attack may be stated as from five to fourteen days, but complete 
convalescence may be postponed for weeks or months on account of the 
occurrence of some of the sequelse so frequent after this affection. On the 
other hand, death may occur at any period from the first day, as above 
stated, to as late as months after the original attack. Hirsch states that 
its duration is between a few hours and several mouths. 

Convalescence may be prompt, satisfactory, and complete ; or it may be 
irregular and protracted, in consequence of the persistence of some symp- 
toms or the development of some of the sequelae. Among them may be 
mentioned blindness and deafness due to causes already stated. Some 
neuralgic pains, dependent upon irritation of the posterior roots of spinal 
nerves, tonic or clonic spasm of certain muscles, and more rarely paralysis 
of a single muscle or of one or more members. It will be observed that 
these sequela are, for the most part, the results of the inflammation of the 
cerebro-spinal meninges. 

The mortality varies greatly iu different epidemics. According to Hirsch 
it has varied from 20 to 75 per cent. As we have met with it in this city, 
the mortality was about 33 per cent. 

The prognosis should always be guarded in epidemic cerebro-spinal men- 
ingitis. Even when the threatening symptoms of the acute attack begin 
to subside, it is impossible to predict that there will not be left behind 
some sequel which may protract convalescence indefinitely or induce a 
lingering and painful death. 

The diagnosis of this disease is not difficult. It could scarcely be con- 
founded with typhoid fever ; but in case of the coexistence of an epidemic 
of typhus fever, it is important to note the differential marks by which this 
latter may be distinguished from epidemic meningitis. Thus the headache 
of typhus fever is less violent and sharp, and the delirium less active and 
marked. In typhus, also, the face presents a dusky flush, and the con- 
junctiva is injected ; while in meningitis the face may be pale at first, and 
the conjunctivae are of a uniform pinkish color. The rapidity of pulse and 
elevation of temperature are much more marked in typhus, and follow a 
much more regular course. The eruption of typhus appears on the third 
or fourth day ; while in meningitis the occurrence of petechise is not at all 
constant, and when present they may appear as early as the first or second 



I 



TREATMENT. 701 

day. On the other hand, the herpetic eruptions so frequent in meningitis are 
wanting in typhus. Vomiting is much more frequent in meningitis than 
in typhus. Retraction of the head, opisthotonos, muscuhvr spasms, neu- 
ralgic pains, cutaneous hyperiesthesia, irreguLarity of the pulse and respi- 
rations also, which are such marked symptoms of meningitis, are not 
characteristic of typhus. We may add that although typhus occurs in 
childhood, it is comparatively rare; while, as we have already seen, epi- 
demic meningitis occurs more frequently among children than at any 
other age. 

We would call attention also to the possibility of confounding mild 
cases;, without eruption, for rheumatism of the cervical and dorsal mus- 
cles. We knew this error to be committed in one case, with fatal results. 

Treatmext. — In the treatment of this affection it is necessary to bear in 
mind its real nature. There can be no doubt, however, that, in the ma- 
jority of cases at all amenable to treatment, the meningeal lesions must be 
the chief object of our medication. 

The use of cathartics is to be adopted with great caution. A mild saline 
laxative may be administered, and it^ action aided by an enema, if marked 
constipation exists at the onset. But it is to be remembered that but little 
food can usually be retained, and also that the constipation is the result 
of the cerebral irritation. 

Opium administered freely, so as to quiet the intense pain and nervous 
restlessness, is to be recommended. Its use will also at times control the 
cerebral vomiting. It is best given by suppository or enema, or in the 
form of morphia by hypodermic injection. 

Bromide of potaj<.-<ium, as a nervous sedative and antispasmodic, may be 
employed with advantage. 

Erf/ot has also been highly recommended on account of its well-estab- 
lished power of influencing congestion of the cerebro-spinal vessels ; and 
certainly this would appear sufficient reason for the employment of this 
remedy alone or in conjunction with belladonna. 

Our own exi>erience agrees with that of most American physicians, in 
p^ard to the beneficial effects of quinine, given in large doses, either by 
the mouth, or, if vomiting be persistent, in the form of suppository. 

Local depletion by leeches or cut cups to the back of the neck and along 
the spine should be employed, unless the evidences of blood dyscrasia for- 
bid it. After its employment, or instead of it, in case it be deemed in- 
admissible, the repeated application of dry cups along the spine is to be 
recommended. 

Food should be very carefully administered in small quantities, and if 
necessary nutritious enemata should be resorted to. 

In ca.se of extreme debility, of depression of the circulation, or of 
tendency to collapse, alcoholic stimulus should be freely employed, and 
the same is true, when, later in the course of the case, the typhoid state is 
markeflly develof)ed. It may also be necessary to apply external wjirmtli 
to maintain the temperature of the body. 

For the relief of the sequehe which result from the imperfect al>--<>rpti(;n 
of the exudation, and the consequent irritation or pressure upon the roots 



702 SCARLET FEVER OR SCARLATINA. 

of the cranial or spinal nerves, evincing itself by neuralgic pains, mus- 
cular spasms, contractions or paralysis, the necessary treatment com- 
prises continued counter-irritation to the spine ; the internal use of iodide 
of potassium, nitrate of silver, or bichloride of mercury ; the use of one or 
the other form of electricity. 



ARTICLE VI. 

SCARLET FEVER OR SCARLATINA. 

Definition ; Frequency ; Forms. — Scarlet fever is an epidemic and 
contagious eruptive fever, characterized by a scarlet rash, which appears 
on the first or second day of the disease, and ends usually about the sixth 
or seventh, or in rare cases as late as the tenth ; by simultaneous inflam- 
mation of the tonsils, and of the mucous membrane of the mouth and 
pharynx ; and which is followed by desquamation. 

The frequency of the disease is exceedingly variable in different years, 
owing to its epidemic nature. This may be readily seen by a glance at the 
following table, which gives the annual mortality for the past sixty years 
in this city, from scarlatina and measles : 





Scarlatina 


Measles. 




Scarlatina 


Measles. 




Scarlatina. 


Measles 


1809 


3 





1829 


9 


53 


1849 


242 


27 


1810 


2 


1 


1830 


40 


7 


1850 


440 


72 


1811 


3 


2 


1831 


200 


23 


1851 


391 


17 


1812 


1 


20 


1832 


307 


118 


1852 


434 


90 


1813 





1 


1833 


61 


1 


1853 


388 


14 


1814 





9 


1834 


83 


7 


1854 


162 


62 


1815 





7 


1835 


305 


248 


1855 


163 


24 


1816 





2 


1836 


240 


4 


1856 


992 


141 


1817 








1837 


205 


49 


1857 


704 


66 


1818 


1 





1888 


134 


123 


1858 


241 


28 


1819 


2 


108 


1839 


225 


136 


1859 


232 


51 


1820 


31 


47 


1840 


244 


2 


1860 


591 


15 


1821 


13 





1841 


83 


119 


1861 


1190 


74 


1822 


9 





1842 


220 


24 


1862 


461 


109 


1823 


11 


156 


1843 


395 


1 


1863 


275 


82 


1824 


9 


102 


1844 


269 


3 


1864 


349 


90 


1825 


9 


38 


1845 


199 


90 


1865 


624 


54 


1826 


4 


101 


1846 


221 


6 


1866 


491 


221 


1827 


1 


9 


1847 


344 


77 


1867 


367 


83 


1828 





58 


1848 


172 


99 


1868 


224 


108 



It will be noticed that for five successive years, 1813-17 inclusive, not 
a single death from scarlatina is reported ; and that during twenty years, 
1809-28 inclusive, only 99 deaths occurred from this cause ; while in the 
single years 1856 and 1861, 992 and 1190 deaths respectively are reported. 



FORMS. 703 

Durins: the entire series of sixty yeai*s, there have been 13,016 deaths 
from scarlatina returned. 

Hillier states, that during the eighteen years from 1848 to 18G6, the 
deaths from scarhitiua in London amounted to 52,401. 

It is impossible to estimate the actual relative frequency cf scarlatina 
and measles, owing to the absence of any returns of non-fatal cases. It 
is evident, however, from the above table that, although the mortality 
from measles is also very variable, and thus may for a short time exceed 
that from scarlatina, in a long series of years the latter disease is far the 
more fatal. Thus the number of deaths from measles in this city, during 
the past sixty years, amounts to but 2279. 

MM. Guersant and Blache {Did. dc Med., t. 28, p. 173) state that it is 
less frequent than measles or variola. They added together the cases of 
the eruptive fevei*s collected in 1838 and 1839, by MM. Roger, Rilliet 
and Barthez, and Barrier, in the Children's Hospital at Paris, and found 
that there had only been 157 of scarlet fever ; whilst there were 2G7 of 
measles, and 213 of variola and varioloid. 

The/o?-m.5 of the disease generally enumerated are the simple, amjinose^ 
and maliffuant. Authors differ widely in their descriptions of these three 
forms. Many of the English authors include in the simple form only the 
cases in which there is no affection of the fauces, while the auginose form 
includes all in which there is any throat affection whatever. M. Rayer, 
on the contrary, describes under the head of the simple form the cases in 
which the throat affection is mild, while he considers the anginose form to 
l)e that in which a pseudo-membranous angina occurs. Again, the de- 
scriptions of the malignant form are vague and uncertain, some including 
under this terra only the rapidly fatal cases in which cerebral symptoms 
are present, while others include those also which are rendered malignant 
by the occurrence of pseudo-menlbranous angina. 

We believe this division of scarlet fever into distinct forms and varie- 
ties to be, for several reasons, a faulty arrangement. It is not, it appears 
to as, in the first place, consonant with the nature of the disease. Scarlet 
fever h, in fact, with all its degrees of severity, and apparent differences, 
a single and di.stinct fever, produced by one cause, determining similar 
effect*, howsoever much they may vary in degree, and requiring no more 
than does typhoid fever to be divided into the variety of different forms, 
which it has been customary to ascribe to it. Again, the above mode of 
division is not, we are sure, a good one for practical purposes. It is im- 
possible, indeed, as we have often found it, to refer many cases we meet 
with in practice, clearly and satisfactorily to any one of the forms of the 
disease described in books. The simple form of some of the English 
writers, or that in which there is no anginose affection, has no existence 
whatever, so far as we have been able to discover. We believe that in- 
flammation of the mucous membrane of the fauces constitutes an essential 
element of the disea.se, for we have never yet seen a case of scarlatina 
in which it was not present to a greater or less extent. It is often very 
slight, so slight, indeed, as to be unaccompanied by any evidence of pain 
in the part, but in all that we have examined, it has been decided and 



704 SCARLET FEVER. 



obvious. This supposed form of the disease does not, therefore, in our 
opinion, exist. 

The two other forms usually described, the anginose and malignant, are 
also of little value practically, since we have found that in all severe or 
grave cases, in which the patient did not die with violent nervous symp- 
toms under the first shock of the scarlatinous poison, there has been de- 
veloped a severe and dangerous anginose inflammation about the third or 
fourth day ; so that it is fair to say that we cannot imagine any malig- 
nant case, lasting over the third or fourth day, which is not anginose, nor 
any severe anginose case, which might not also be styled, from its danger- 
ous character, malignant. We have found it impossible, in our experi- 
ence, to draw the distinction clearly and indubitably between the anginose 
and malignant varieties, because all severe cases partake more or less of 
the features of both. 

Feeling this difiiculty of describing the disease according to the mode 
that had before that time been generally followed, and believing it also to 
be insufficient for practical purposes, we were led to attempt, in the first 
edition of this work, a different arrangement. 

We made, accordingly, two forms or degrees of the disease, which we 
designated by the terms regular and grave. In the first form or degree 
we included all the cases in which the angina was simple and the eruption 
regular in all respects ; in which there was no predominance of one set of 
symptoms over another, but in which all held a due relation to each other. 
In this form was embraced all the cases of scarlatina simplex of writers, 
and many of those of scarlatina anginosa of the English authors. In the 
second form we included the cases which departed from the regular course 
of the disease, and which were rendered dangerous by the occurrence of 
severe symptoms not belonging in the same degree to the simple affection. 
This form we subdivided into two varieties, the grave anginose, which con- 
tained all the cases accompanied by pseudo-membranous, ulcerative, or 
gangrenous angina ; and the grave cerebral, which comprised all those 
marked by the early occurrence of dangerous cerebral symptoms. The 
grave form comprehended, therefore, some of the cases of scarlatina angi- 
nosa, and all those of scarlatina maligna of writers, dividing, however, 
those in which a pseudo-membranous, ulcerative, or gangrenous angina 
determined the type of the attack, from those in which the cerebral or 
nervous symptoms gave to the case its stamp. 

More extended observation and more patient reflection have taught us 
that this division also is incorrect, — that it does not afford a good classi- 
fication for the purposes of description, and that it is defective as a guide 
in practice. 

We adopted, therefore, in the third edition, and shall follow in the 
present one, a different method of considering the disease, one which we 
believe to be more consistent with its nature, more suitable for the pur- 
pose of description, and much more likely to prove useful in practice. 
We shall follow the same arrangement in regard to scarlet fever as that 
now generally employed for typhoid fever. We shall consider it as a 
single and distinct disease, and not as made up of a number of uncertain 



1 



CAUSES. 705 

and imperfectly separated forms or varieties, since these so run into each 
other, as to make it absolutely impossible to draw the line clearly and 
palpably between them. The only division we shall make will be into 
mild and ffrave cases, since the only real difference between the cases is a 
difference in the degree of severity they exhibit. 

Causes. — It has been abundantly proved by long and reiterated ob- 
servation that scarlatina is propagated by two causes, contagion, and epi- 
demic influence. Of these two modes of propagation, we have not the least 
doubt ourselves that the latter is by far the most active. It is only neces- 
sary to look over the results afforded by the tables of mortality for this 
city, as quoted in the early part of this article, and to observe that in some 
years the disease caused a heavy mortality, in others a very small one, 
and that in others again not a single death from it is reported, to be con- 
vinced that it is of a highly epidemic nature. 

The coniaf/ious character of scarlatina has been doubted by some few 
persons, but seems to us clearly proved by the evidence adduced by 
various writers. Our own experience also convinces us that it is a con- 
tagious disease, though much less so, we are sure, than either small-pox, 
measles, hooping-cough, or chicken-pox. We have quite frequently, in- 
deed, known children exposed directly and for a considerable length of 
time to the infection to escape entirely, while it is extremely rare for us to 
meet with children, unprotected by previous attacks, who can resist the 
contagion of measles, hooping-cough, or varicella. But, though we believe 
it to be much less highly contagious than has been generally supposed, and 
than the other contagious diseases just named, we are also well convinced, 
a.s was stated above, that it is propagated to a considerable extent by a 
direct contagion. We have, in a number of instances, known one child in 
a family to contract the disease from direct exposure to it, or from the 
epidemic constitution of the atmosphere, and a second, third, and even a 
fourth, to take the disease from the first, in five, seven, or nine days after 
the latter had fallen sick. In other instances, on the contrary, it would 
eeem that cither several children in one family contract the disease nearly 
gimultaDeously from the epidemic influence, or else that the period of in- 
cubation is sometimes very short. For example, during the winter season, 
a child five months old, who had never been out of the house, was seized 
with it. On the second day after the eruption appeared on this child, her 
sister, between four and five years old, fell sick, and on the third day 
another sister, the only remaining child, between two and three years of 
age. In the first of these cases it must have been contracted through the 
epidemic influence which was at that time prevalent in the city, since the 
child had in no way been directly exposed to it. In the other two, we 
niU't either suppose the cause to have been the same, or else that the period 
(){ iiK iiliation was only two and three days in the respective cases. 

The period of incubation is shorter than in other contagious eruptive 
diseases. It may be stated to vary between twenty-four hours and two 
or three weeks. MM. Guersant and Blache are of opinion that in the ma- 
jority of cases, it is from three to seven days. MM. Rilliet and B^rthcz 

46 



i06 



SCARLET FEVER. 



found that of 38 cases in which the time was recorded, it was between 
and 7 days in 16, between 8 and 13 in 15, and 15 and 40 in 8 cases. Our 
own observation would fix it at from 9 to 15 days in the majority of cases. 

Occasionally, however, it is very short ; thus Trousseau mentions a case 
in which the evidence is almost conclusive that the period of incubation 
was less than twenty-four hours. Murchison also states that this latent 
period varies from a few minutes to five days, rarely, if ever, exceeding 
six days. 

It is impossible to state with any certainty the length of time during 
which the power of imparting the contagion continues in the patient. 
M. Cazenave {Ahrege Prat, des Mai. de la Feaii, p. 54), states that it lasts 
throughout the period of desquamation, and that it would even seem to be 
most active at that time. 

Whatever may be the duration of this period, it is certain that the virus 
may attach itself to clothing, bedding, or furniture, and that the disease 
may thus be transmitted by one who is not himself attacked. We also 
learn from some remarkable instances, as for example, from a case related 
by Richardson in " The Asclepiad,'' that when the virus is thus attached to 
fomites, it may retain its activity for many months. 

In regard to the essential nature of the poison, it appears probable, in 
the first place, that it is contained in the secretions of the skin and fauces. 

The distance to which it may be carried by the air does not appear to 
exceed a few feet, and in those cases where prompt isolation does not pre- 
vent the communication of the disease, the virus has either been previously 
imbibed or is carried by fomites. It is probably of material nature, and 
is admitted to the system either through the skin, the respiratory, or, per- 
haps, the gastric mucous membrane. 

As we have seen, it retains its activity for a long time; but is rendered 
inert by a temperature somewhat below 212° F. 

Scarlatina is stated to be also inoculable, by the blood, the secretion 
from the fauces, and the fluid from the miliary vesicles which occasionally 
form on the skin. The resulting disease appears in some instances to have 
been favorably modified, but the operation has been comparatively rarely 
practiced. 

The epidemics of scarlet fever vary exceedingly in their extent and 
violence. During the years 1842 and 1843, the disease prevailed very 
extensively in this city, and assumed a malignant type, so that in a con- 
siderable number of families, two, three, and even four children, died 
within a very short period. 

During the winter of 1856-7, and throughout the spring of 1857, we had 
one of the most prevalent epidemics that ever visited this city, and yet the 
proportion of deaths to the whole number of cases in our own practice and 
that of our friends, was such as to seem to show that the type of the epi- 
demic was mild. 

The disease prevails at all seasons, but is most frequent in the spring 
and summer, and next in the autumn. It rarely occurs more than, once 
in the same individual, but that it does so sometimes, is proved by facts 
brought forward by difi'erent authors. It has been asserted that second 



INFLUENCE OP AGE. 707 

attacks of scarlet fever occur in the same person not more than once in a 
thousand cases. Of the truth of this assertion we are, however, very doubt- 
ful, since it has occurred to us to see no less than three examples of second 
attacks in our own experience. We attended in this city one child with 
perfectly well-marked scarlet fever, attested by subsequent anasarca, who 
had had the disease two years previously under the care of the late Prof. 
C. D. Meigs. In the winter of 1852, we attended two children in one 
family with the disease, one of whom died, and both of whom had had the 
disease four years and a half before. They were attended in the first 
attack by one of oui*selves, and as it chanced, owing to our absence from 
town during one day, they were seen also by one of our friends, who made 
no exception whatever to the diagnosis of scarlet fever. The only doubt 
as to these cases having been veritable examples of double attacks of the 
disease, must rest of course upon the diagnosis. In the first example, the 
diagnosis was made by Prof ^Nleigs in the first attack, and by one of our- 
selves in the second. In the two latter it was made by one of ourselves in 
both, accidentally confirmed in the first attack, in both children, by the 
opinion of a competent professional friend. The first attacks in the latter 
cases were both mild, but well marked ; the second were both severe, and 
one proved fatal on the sixth day. We have not the least doubt ourselves 
that all of the three were cases of true scarlet fever. If they were not, 
the two latter must have been cases of roseola, so closely resembling scar- 
latina as to oblige us to confess ourselves incompetent to distinguish be- 
tween the two diseases. What adds to the certainty that the two which 
came under our own observation were examples of scarlet fever, is the fact 
that they occurred simultaneously with a third case in the same family. 
Now, roseola is not apt, so far as we know, to occur epidemically in a 
household. Most of the cases of that disease that we have seen, have been 
solitary ones. Again, in the spring of 1857, one of us saw a well-marked 
attack of the disease in a boy nearly four years old, who had had it one 
year l)efore, under the charge of a perfectly competent practitioner. 

Dr. Richardson (/oc. cit.) asserts that he has known the disease to occur 
twice in the same patient, and also states that he himself has suffered from 
it three times. 

Ag*. — MM. Rilliet and Barthez state that it is most common from six 
to ten years of age. Of 251 cases that we have seen, in which the age 
was noted, 64 occurred under 3 years of age, 78 between 3 and 5 years, 51 
between 5 and 7, 47 between 7 and 10, and 11 between 10 and 15. From 
thi"* it would appear to be more common in the first five years than be- 
tween the ages of five and ten, since of the 251 cases, 142 occurred in the 
former, and only 98 in the latter period. By uniting the statistical tables 
of Dr. Emerson with those of Dr. Condie (DU. of Child, 2d ed., note, p. 
86), we obtain the deaths from scarlatina in this city at different ages for 
a jK'riod of thirty years. These tables show clearly that the disease is 
mont common between the ages of one and five years. The total mortality 
from scarlatina under ten years, during the time stated, was 2171, of 
which 132 were under one year of age, 411 between 1 and 2, 1130 between 
2 and 5. and 510 between 5 and 10. 



708 SCARLET FEVER. 

Of 148,829 cases collected by Dr. Murchison from the death returns of 
Great Britain, 9999, or about 7 per cent., were under 1 year; 30,974, or 
20 per cent., under 2 years ; 95,070, or 64 per cent., under 5 years ; 38,- 
591, or 26 per cent., between 5 and 10; and but 13,168, or about 9 per 
cent., at all ages above 10. 

This agrees quite closely with the averages calculated from the exten- 
sive statistics collected by Dr. Richardson, which show the following per- 
centage at different ages : 

Under 5 years, . . . ... . . 67.63 

From 5 to 10, 24,33 

" 10 to 20, 5.52 

" 20 to 40, . 1.73 

" 40 upwards, 0.66 

Out of 12,962 deaths under 5 years, 1289, or 9.9 per cent., were under 
1 year ; 2874, or 22 per cent., between 1 and 2 ; so that 4163, or 31.4 per 
cent., were under 2 years. 

The earliest age at which w^e have seen it perfectly well marked, was 
twenty-one days. We saw it once also in a child five months of age, and 
twice at the age of six months. It is not nearly so common in the first 
year of life as it is afterwards. The largest number of cases occur, accord- 
ing to our experience, in the third, fourth, and fifth years of life. 

The influence of sex seems not to have been determined with certainty. 
Dr. Tweedie {Cyclop, of Prac. Med., art. Scarlatina), says it is most com- 
mon in girls. MM. Rilliet and Barthez, on the contrary, state it to be 
more common in boys. Of 262 cases under 15 years of age that we have 
seen, in which the sex was noted, 133 occurred in males, and 129 in 
females. The truth is, probably, that under puberty it attacks the two 
sexes with about equal frequency, while after that age it is most common 
in females. 

It occasionally happens, that patients, both adults and children, who 
have undergone surgical operations, are attacked with a scarlatinous rash, 
with mild constitutional symptoms (Hillier, Gee). The disease, accord- 
ing to these authorities, is true scarlatina ; and its occurrence at that time 
probably depends upon the system being in an unusually favorable condi- 
tion for the reception of the virus. 

Symptoms ; Course ; Duration. — As has already been stated, we in- 
tend, in our description of the symptoms of scarlet fever, to depart from 
the ordinary mode of arrangement of the subject. We shall discard the 
old division of the disease into three forms or degrees, scarlatina simplex, 
anginosa, and maligna, and substitute, for reasons already given, the sim- 
ple division into mild and grave cases. We shall class as mild cases those 
which pursue an even and regular course, without being accompanied by 
dangerous or malignant symptoms, in which there occur neither violent 
nervous, nor threatening anginose symptoms ; while among the grave cases 
we shall place those in which there occur severe nervous symptoms, in the 
form of violent delirium, coma, or convulsions, dangerous symptoms in the 
form of diphtheritic, ulcerative, or gangrenous inflammation of the mucous 



SYMPTOMS OF MILD CASKS. 709 

membrane of the fauces, and finally, those iu which the general symptoms 
assuFiie a low and typhoid character. When it seems convenient, we shall 
follow the usual division of the course of the disease into the three stages 
of invasion, eruption, and desquamation. 

Mild Cases. — Stage of Invasion. — The following description of the symp- 
toms of scarlet fever in its mild form is drawn partly from books, but 
much more from our own observation of several hundred mild cases of the 
disease, of 213 of which we have kept a faithful record, and, when there 
wa.s anything peculiar or important, full notes. 

The onset of mild cases of scarlet fever is generally sudden. A child 
is well, or so slightly ailing on one day, as that the change from its usual 
condition is not noticed at the time, though it may be recollected afterwards, 
and on the following day, or often within twelve hours or even less, the 
symptoms of the disease become marked and characteristic. In a large 
majority of the cases that we have seen, the eruption was already visible 
at our first visit. Frequently the patient has been put to bed well in the 
evening, and, becoming restless and feverish in the night, is found on the 
following morning with fever, sore throat, and very considerable eru})tion ; 
or, as happened in one of our cases, a child gets up in the morning appar- 
ently well, breakfasts as usual, goes to church, and falling sick while there, 
comes home and, a few hours later, shows the eruption over the neck and 
upper part of the trunk, and has fever and sore throat. In another case, 
a boy between seven and eight years old was perfectly well in the morn- 
ing. At 2 P.M., his mother, a most sensible and accurate person, observed 
him playing in the garden, and remarked upon his healthy looks. Fifteen 
minutes after this he felt sick at his stomach ; he came into the house and 
went up to the nursery, looking pale and pinched, with a cold skin, and 
nearly fainted in the nurse's arras. He had then in the course of an hour 
three copious and watery stools, each one accompanied with vomiting. 
We saw him one hour after this, dozing, very pale, with pinched features, 
sunken and half-clased eyes, cool surface, and with the pulse at 128, and 
rather feeble. There was no eruption. At 6 p.m., we found him with a 
hot and dry skin, with the tongue heavily coated, the fauces swollen and 
ghowing flecks of exudation upon the tonsils, a pulse at 128, and with a 
well-marked scarlatinous eruption coming out abundantly. The case 
pursued a verj' regular course, without dangerous or malignant symptoms 
of any kind. 

But the invasion, though sudden in nearly all cases, is not always so 
precipitate as we have just described. When we come to analyze the early 
symptoms, we find that the first one observed in most of the cases is fever, 
marked by considerable acceleration of the pulse and heat of skin. In 
soMu- few ca.«es the fever is preceded by the ordinary prodromes of febrile 
di-(:i-*s, languor, la-ssitude, pains in the back and lind)s, and slight rigors. 
Simultaneously with the fever there is in nearly all cases more or less sore- 
ness of the throat. In all that we have examined, even those in which no 
pain waa complained of, there has been redness, or redness with swelling 
of the fauc-es. In a majority of the cases vomiting occurs, or if not vomit- 
ing, some degree of nausea. There is complete anorexia; the thirst is 



710 SCARLET FEVER. 

acute ; the bowels are usually in their natural condition, or slightly con- 
stipated. The child is quiet and dull, or else restless and irritable, and 
sometimes there is delirium; the face is generally flushed, and the eyes 
often slightly injected. The duration of these symptoms is irregular. 
They are said to last generally about a day, but they may continue either 
a shorter or longer period. We are very sure, from our own observation, 
as we have already stated, that these preparatory symptoms rarely precede 
the eruption more than twelve hours, and very often the time is even less, 
so that the eruption may even be the first symptom noticed. 

Stage of Eruption. — The eruption generally appears first on the face and 
neck, whence it extends rapidly over the whole surface. It continues to 
increase in extent and intensity, so as to reach its maximum about the 
third or fourth day. It appears first in minute dark-red points dotted 
upon a rose-colored surface, forming patches of irregular shape, of consid- 
erable size, level with the skin, disappearing under pressure, divided at 
first by portions of healthy skin, but running rapidly together, and giving 
to large portions of the surface a uniform scarlet color. The eruption is 
not generally equally difiused over the whole body, but is more marked 
upon one portion than another. It is often most intense on the back, and 
is there of a deeper color than elsewhere, not unfrequently assuming a 
purple hue. It is generally very well marked on the abdomen and thighs, 
and about the articulations, and assumes in those regions a particularly 
bright tint. 

It does not always cover the whole surface, but in some very mild cases, 
and, as we shall find when treating of the grave cases, in these latter, also, 
it may occur only in patches of moderate extent upon different portions 
of the body, leaving us at times in some doubt as to the real nature of the 
rash. 

The surface of the eruption is smooth and even to the touch, unless, as 
not unfrequently happens, it is accompanied by the development of miliary 
vesicles, or crops of minute pimples or pustules. A certain degree of rough- 
ness is sometimes occasioned also by enlargement of the papillae of the skin 
in various parts of the body, particularly on the extensor surface of the 
limbs ; but these are evidently independent of the characteristic eruption. 
The skin upon some parts of the body, especially the face, hands, and feet, 
often presents a swollen appearance, rendering the movements somewhat 
stiff. There is in most cases a feeling of burning, irritation, and itching 
in the skin, the latter of which symptoms increases as the malady pro- 
gresses. 

If the nail be drawn firmly over the skin where the eruption exists, a 
white line is produced, which lasts for a short time and then passes away; 
if the pressure be more firm, a central red line with a white streak on either 
side is developed. This was originally pointed out by Bouchut as pathog- 
nomonic of scarlatina, the peculiarity, according to him, consisting in the 
great duration of the white line so caused. It does not appear, however, 
to have any positive value in distinguishing this affection from many forms 
of erythema. 

The eruption generally reaches its height about the fourth day, and 



SYMPTOMS OF MILD CASES. 711 

then remains stationary for one, or less frequently two days, after whieh 
it begins to decline. Its decline is marked by a diminution in the in- 
tensity of the color, which, from scarlet, becomes red, then rose-colored, 
and growing paler and paler, finally disappears entirely about the sixth, 
seventh, or eighth day. In some very mild cases, however^ the whole 
duration of the eruption is not over two or three days, and in such the 
color it imparts to the skin is never very bright nor very deep, nor is it 
accompanied by intense heat, or by much irritation or itching. 

The symptoms which preceded the eruption do not subside on its ap- 
pearance, but persist or are augmented. The febrile movement continues 
unabated ; the pulse is full, strong, and frequent, running up very soon 
after the onset to 120, 140, 150, and often to 160. This frequency of the 
pulse is, in fact, one of the most marked symptoms of the disease. We 
have rarely, even in very mild cases, found it less than 140, and in not a 
few it has beeu in the first few days, and in children of four or six years 
old, even as high as 168 or 170. Occasionally, however, it has been lower, 
and in a case that occurred to one of us, in a boy five years old, it was 96 
on the second day, and only 88 on the third, though there was still a good 
deal of rash upon the skin. The skin is burning hot and dry, as a gen- 
eral rule, and loses its usual softness and suppleness. The expression of 
the face is usually natural. The eye is often animated, and slightly in- 
jected. The respiration is generally easy and natural, though sometimes, 
when the fever is violent, it becomes quickened. The auscultation and 
percussion signs are natural, unless some complication exists. There is 
often a rather frequent cough, which is dry, and evidently depends on the 
guttural inflammation, and not on any bronchial or pulmonary aflTection ; 
it exists during the early period of the eruption, and declines with the in- 
flammation of the fauces. The voice is seldom altered beyond having a 
nasal sound, so long as the disease continues simple and regular. If the 
voice becomes hoarse or whispering, it indicates an extension of the in- 
flammation from the pharynx to the larynx. The anorexia continues 
until the eruption begins to decline, and the thirst is acute up to the same 
period, when it moderates. At first the dorsum of the tongue is covered 
with ar whitish or yellowish-white fur of variable thickness, while its tip 
and edges are of a deep red color. After two or three days, and during 
the course of the eruption, the coating just described disappears from the 
toDgue, and its whole surface assumes a deep red tint and a shining ap- 
pearance, which makes it look like raw flesh. At the same time it is often 
much diminished in size from contraction of its tissues, and its papilhc be- 
come enlarged and projecting; this condition generally lasts from six to 
ten days, after which it returns to its natural state; it is commonly moist 
throughout the attack. Vomiting is rarely troublesome in mild cases, 
though it often occurs; the bowels continue nearly in their natural con- 
dition; in some few ca.ses slight diarrhffa occurs, but more frequently 
there is very moderate constipation. The abdomen is natural in most of 
the cartes; sometimes, however, there is slight distension and pain for a 
few days, which coincide generally with enlargement of the liver, or more 
rarely of the spleen. 



712 SCARLET FEVER. 

The uriue during this stage usually presents the ordinary febrile char- 
acters ; it is diminished in quantity, often of high color, though the pig- 
ment is not necessarily increased. The urea is not increased, which Einger 
regards as indicating that the kidneys are affected from the beginning of 
the attack. The chlorides are always more or less diminished. The phos- 
phoric acid, according to Dr. Gee, is about normal for the first three or 
four days ; it then diminishes, and remains for a few days at a half or a 
third of its normal amount. Uric acid appears to be retained during the 
pyrexia, and excreted in excess so soon as it begins to subside. Accord- 
ing to Holder's examination of 17 cases, there is bile pigment present 
during the first six days. 

Early in the second, or even in the first stage, the fauces present the 
signs of inflammatory action ; the pharynx is reddened, and in some in- 
stances swelled ; the tonsils enlarge and become red ; the submaxillary 
and lymphatic glands are somewhat tumefied and tender to the touch, and 
when the case is at all severe, deglutition is generally painful, and in some 
instances extremely so. The absence of complaints of sore throat in a 
child, or the fact of its swallowing without hesitation or apparent diffi- 
culty, is no proof that angina does not exist, since we have always found 
upon examination in a good light much greater redness than natural, and 
in many instances redness and swelling combined. As the eruption pro- 
gresses, and the tongue loses its coat and becomes red, the inflammation 
of the pharynx usually augments ; the redness becomes deeper, and the 
tonsils are more swelled and painful, and, in a good many, but not by any 
means all the cases, are dotted over with small white spots, or with thin, 
whitish, and soft false membranes. The throat-affection, however, is rarely 
severe enough to constitute a serious danger in mild scarlatina, while in 
many of the malignant cases it is a frequent cause of a fatal termination. 
During the eruption, the nostrils are either dry and incrusted, or there is 
some coryza. The strength of the child is reduced for the time, but 
there are no signs of prostration, and the decubitus is indifferent. There 
is almost always more or less disorder of the nervous system, sometimes 
amounting only to headache and restlessness, while in other instances 
there is great irritability, wakefulness, and occasional delirium, especially 
at night. 

Stage of Decline and Desquamation. — The eruption reaches its height, as 
already stated, about the third or fourth day, then remains stationary for 
one or two days, and afterwards declines gradually, so that no traces are 
left on the sixth, usually, or at most, in rare cases, on the ninth or tenth 
day. In some very mild attacks, the whole duration of the eruption is not 
over two or three days. By the third day it has disappeared entirely. 
Such cases are not, however, very common. The other symptoms, both 
general and local, decline with the eruption : the pulse loses its frequency, 
and falls to the natural standard ; the heat of the surface first subsides and 
then disappears, but the skin remains somewhat harsh ; the redness and 
swelling of the tonsils and pharynx diminish ; the spots of false membrane, 
if these be present, are thrown off"; the deglutition becomes easy if it have 
been difficult, and soon all signs of throat-affection vanish ; the tongue 



SYMPTOMS OF MILD CASES. 713 

cleans off, becomes reddish aud glossy, and after a time returns to its 
natural state. 

At the time that the subsidence of all the symptoms takes place, dei^qua- 
matioH begins. It dates, therefore, in most cases from about the sixth day, 
though it may be either earlier or later. According to Hiller, the date of 
commencement varies from the sixth to the twenty-fifth day. It com- 
mences in most of the cases on the face aud neck, though in a few instances 
it appears first on the abdomen. It then extends gradually over the body 
and becomes general. About the thorax and abdomen it occurs in the form 
of minute points, like those which result from the desiccation of sudamina; 
on the face it is in the form of thin light scales or squama^ while ou the 
extremities large flakes of the epidermis become separated from the derm, 
and are removed by the child, or rubbed oflT by his movements in bed. 
The whole process usually occupies some ten or twelve days, but may be 
prolonged into the third week, or even until the middle of the second 
month. It is generally accompanied by roughness aud dryness, and some 
itching and irritation of the skin. Not unfrequently, the surface beneath 
the exfoliation is left tender and irritable for some time afterwards. 

During this period, dating from the sixth or eighth day, the urine be- 
comes abundant, pale, of neutral or faintly acid reaction, and, according 
to Gee, deficient in phosphoric acid. 

Albuminuria is also frequently observed during desquamation, very 
much more so than during the eruptive stage. It is usually transient, 
but may continue until dropsy occurs. Sometimes the albumen totally 
disappears, and reappears when dropsy comes on a fortnight or three 
weeks later. The proportion of cases in which this form of albuminuria 
is present varies in different epidemics, from twenty-five or thirty to ninety 
j>er cent. 

Temperature. — The fiery redness of the surface and the pungent char- 
acter of the heat, have led to much exaggeration in the description of the 
pyrexia in this disease. The range of temperature is indeed from 100° 
to lOo", and only in rare cases does it reach 106°. 

In 30 cases reported by Ringer (Med. Times and Gaz., Feb. 15th, 1862), 
the temperature remained at the same point throughout the day in the more 
severe attacks ; in slighter ones, it fell in the morning and rose during the 
day, l>eing most frequently at its highest point between 2 and 8 r.M. 
AVhen the morning remission was marked, it indicated the approach of a 
favorable termination. The first decided fall of temperature, coinciding 
with a diminution in the eruption, occurred in the majority of cases on the 
fifth day, or if not on this day, it usually was deferred until the tenth or 
fifteenth. In these latter cases, however, a fall of varying extent had oc- 
curred on the preceding fifth days. After the marked fall on the fifth, 
tenth, or fifteenth day, the temperature remains from 99° to 101° for a 
variable time, coinciding when persistent with continuance of the angina, 
or some of the other lesions of the disease. If at any time after the com- 
plete fall of the temperature, there is any considerable elevation again, it 
indicates the development of some sequel, either an afl^ection of the kidneys, 



714 SCARLET FEVER. 

throat, or oue of the serous membranes. It is thus seen that the tempera- 
ture in scarlatina tends to form ares or cycles, usually of five days' duration. 

Before quitting this part of our subject, we must remark that, though the 
above is a correct description of the usual symptoms of mild cases of this 
disease, the reader would be greatly deceived should he expect always, and 
invariably, to find this exact train of morbid phenomena. On the contrary, 
the mild and the grave cases both vary so much, that it is impossible to 
describe them accurately by one or two portraits. Taking the above sketch 
as a standard of the mild cases, the observer will find that many fall short 
of it in all their features, while others deepen gradually in their shades, so 
to speak, until they pass into the grave type. Those that are milder in 
their type than the above sketch, may be so in such a degree as to make 
it very difficult, and in some cases impossible, to determine positively 
whether the child has had the disease or not. Indeed, we doubt not our- 
selves that children sometimes have the disease so slightly, that it is not 
discovered by either the physician or parents, and, being protected by the 
attack, are in after-life classed amongst those insusceptible to the disease. 
Our grounds for asserting this are the facts that some cases we have seen 
have been so very mild that, but for the existence of the disease amongst 
other members of the family, they might have passed unobserved ; and 
that in one instance we were sent for to see a patient, who had had the 
eruption for three days, and yet who was so slightly sick that he was sent 
for from school, to which he had gone, for us to see. It was a well-marked 
case, and the child had no troublesome symptoms afterwards, notwith- 
standing the exposure he had undergone. 

A. still more remarkable case occurred to one of us two years since, 
which shows clearly how a child may take scarlet fever without its being 
recognized by the family. 

Cask. — The mother of one of the families we attend consulted us about one of 
her sons, a sturdy boy of seventeen years of age. She stated that hn had not been 
well for two days ; that he had a severe sore throat, was restless and feverish at night, 
could eat nothing, and complained of debility, but, as he was then going through 
his examination at the High School of this city, he refused obstinately to remain 
at home. It was agreed that he should call at our oflBce the next morning, on his 
way to the school. When he arrived, which he did on foot, as usual, we found him 
covered with a copious, dark-red, perfectly characteristic scarlatinous eruption; 
his throat was very red, swollen, and quite painful ; the pulse was over 120, active 
and full, and the skin hot. He was, of course, ordered home, there to remain until 
perfectly well. He recovered and had no drawback. The distance from this 
boy's home to his school was not less than a mile and a half, and he had walked 
this distance twice a day. 

Grave cases. — The following description of the symptoms of grave cases 
of scarlet fever is, like that which has just been given of the mild cases, 
drawn partly from books, and partly from our own observation of the 
disease. We have had the opportunity of carefully observing a very 
large number of grave cases of scarlatina, but we find that we have pre- 
served a more or less complete record of but 61 such cases. We shall 
include under this division of the subject, as already stated, most of the 



SYMPTOMS OF GRAVE CASES. 715 

cases usually classed by writers under the title of scarlatina angiuosa, and 
all tliose generally described under the title of scarlatina maligna. 

The symptoms which mark the invasion of grave cases of scarlet fever, 
though sufficiently alike in all to show the unity of the disease, diifer very 
materially as to their degree of severity in different cases. In one set 
(rather less than a third, or 18 in 61, of our cases) they are most violent 
and dangerous, or, indeed, appalling in their character. From the first, 
they declare the imminent danger of the attack. In the second set (rather 
more than two-thirds, or 43 in 61, of our cases), they may be either evi- 
dently severe and dangerous, though not appalling, as in the first, or they 
may be much milder, more like those which mark the invasion of mild 
cases; but even under these circumstances they soon put on their grave 
and dangerous character. 

The first set of cases, or those in which the symptoms are the most severe 
of all, and which include most of the malignant cases ordinarily styled 
ataxic, usually begin with nervous symptoms. The onset is in some in- 
stantaneous. In one, the little patient, a girl two years old, whose brother 
and sister had been sick for some days with scarlatina, was put to bed in 
the evening in her usual health, which was strong and vigorous. She 
slept quietly through the night, but was found by the mother the next 
morning in a state of drowsiness, violent fever, and covered with a deep- 
red scarlatinous rash. She soon became comatose, and died on the third 
day. In another case, a boy eleven months old was a little fretful in the 
afternoon, but was put to bed in the evening as usual and went to sleep. 
About ten o'clock the nurse heard a rustling in the bed, and on going to 
it found him in a violent general convulsion. The next morning he was 
covered with a scarlet rash, which became deeper and deeper as the disease 
went on. On the second day he was nearly insensible, and had frequent 
attacks of convulsions ; on the third day he had retraction of the neck, 
with spasmodic twitching>, and at the end of that day died in a state of 
cuma. In a third case, a boy six years old, whose sister had been sick for 
a week with a mild attack, went to bed well. At three o'clock in the 
morning, he was seized with vomiting and purging, paleness and coolness 
of the skin, and great exhaustion. At nine o'olock he was drowsy and 
dull, the .-kin was pale and cool, and the pulse extremely rapid ; the vomit- 
ing and purging had ceased ; at 12 m. he was comatose and had a convul- 
sion. From this time he continued comatose until he died at 6 r.M. of 
the .«ame day, after an illnes.s of fifteen hours. In a fourth instance, the 
invasion was that of croup; after a few hours came on coma and convul- 
sions; patches of eruption then appeared on the trunk, and death occurred 
in twenty-four hours from the beginning. The subject of this case, a boy 
five years old, was thought to be so well in the afternoon of the day he was 
taken sick, that he had been sent out to visit a relation, and while there 
fell sick. In the fifth case the onset was sudden, with violent fever, 
drowsiness, deep suffusion of the skin, and in a few hours insensibility, 
general convulsions, and death in thirty-six hours. In a sixth, in a boy 
four yean* old, the attack came on with vomiting, palenes«, drowsiness, 
and then a scarlet rash ; after a few days, coryza and otorrhtt«a occurred ; 



716 



SCARLET FEVER. 



the tongue and lips became cracked and dry; in the second week the 
child was comatose, with occasional attacks of extreme jactitation, and 
the most violent hydrocephalic cries, which condition lasted ten days. 
After this there was diarrhoea, extreme emaciation, loss of speech, and 
entire deafness. Gradually, however, the fever disappeared, the tongue 
cleaned off, and intelligence very slowly returned ; in the sixth week con- 
valescence was firmly established, and the child recovered perfectly with 
the exception of his hearing, which remained very dull in consequence of 
the perforation of both membranse tympanorum. In a seventh, a girl 
eight years old, whose brother was then sick in the house with the disease, 
was in the morning well. At breakfast, she said she felt sick and soon 
went to bed. At 5 p.m. of that day she was attacked with a general con- 
vulsion, which lasted about fifteen minutes. The pulse, immediately after 
the convulsion, was 150. At 11 p.m. she had another convulsion. Through 
that night she was very restless and wandering. On the morning of the 
second day there was a third convulsion, which, however, was very short. 
The pulse was now 160, small, and feeble. The patient was very heavy 
and dull, answering questions slowly and with great diflSculty, and during 
part of the day she was comatose. On the third day she was better, the 
pulse having fallen to 152, and she was less dull, though she still con- 
tinued very heavy and inattentive unless aroused by persevering efforts. 
The limbs were cool, while the head and trunk were hot. The eruption 
was thick on the trunk and upper part of the extremities ; elsewhere it 
was scanty. Wherever it existed, it was of a deep red or purplish color, 
and the capillary circulation was sluggish and imperfect. On the fourth 
day her intellectual condition continued better, but the extremities were 
still cold, and the lymphatic glands and subcutaneous tissues about the 
lower jaw and neck had begun to swell. On the fifth day, the swelling 
had become very great ; the stupor had returned; a profuse and disgusting 
coryza and otorrhoea had set in ; and the edges of the eyelids were in- 
flamed and sore. On the sixth day the discharges from the mucous mem- 
branes of the head were very copious, and consisted of a thick, offensive, 
purulent fluid intermixed with dull whitish grumous particles. The 
patient was now comatose or very restless ; she swallowed with great diffi- 
culty; the swelling under the lower jaw and about the throat was enor- 
mous ; the pulse was rapid and small ; the eruption was very dark in 
tint; the cutaneous circulation was slow; the extremities were cold, and 
death occurred about the middle of this day. In another case, the subject 
of which was a girl between three and four years old, the attack began 
with severe inflammation of the throat, causing great difficulty in swal- 
lowing. The rash on the first day was very extensive and of a deep-red 
color. The child was drowsy and heavy, or else delirious. On the second 
day she was comatose, and had strabismus and automatic movements of 
the limbs. On the third day the coma continued, and there were auto- 
matic movements of the extensor muscles, with retraction of the head. 
The eruption continued vivid, but was of a dark-red color. Death occurred 
in the middle of the fourth day, in a state of coma, without convulsions. 
In still another case, a boy, between eight and nine years old, was at- 



SYMPTOMS OF GRAVE CASES. 717 

tacked suddenly, while in g(Xid health, with vomiting, sore throat, and 
high fever. Twelve hours after the onset, he had a severe convulsion, 
which lasted fifteen minutes. He soon recovered from this, however, and 
remained perfectly intelligent. On the second day the rash was moderate ; 
there was violent fever, and the child was heavy, but, wheu roused, still 
intelligent. Early in this day a severe fit occurred. This was most vio- 
lent, as severe as the worst epileptic convulsion. It lasted one hour and 
three-quarters. The pulse, after this, was 145. On the third and fourth 
days, the symptoms improved very much, the pulse having fallen to 125 
and 132, but he continued drowsy and heavy. The eruption came out 
most abundantly. The fauces were very much inflamed, and somewhat 
ulcerated, and the external lymphatic glands were enlarged, but still the 
swallowing was not difficult. On the fifth he was not so well, being more 
restless and heavy alternately. There had now come on much difficulty 
in breathing, and some croupal sound. The latter symptom increased 
through the day, until the dyspnoea became very great. Deglutition now 
became excessively difficult ; the external swelling increased ; attacks of 
suflTocation attended with the most painful and distressing jactitation came 
on, and were renewed more and more frequently ; and death occurred by 
asphyxia about the middle of the sixth day. In a tenth case, in a girl 
five months old, convulsions occurred on the second day. These were 
followed by coma lasting several days, and by enormous swelling of the 
lymphatic glands and subcutaneous tissues on the left side of the neck, 
and by a less degree of swelling on the right side of the neck. The 
glands of both side^ suppurated and were opened, and the child finally 
recovered perfectly. In an eleventh case, in a boy seven years old, an 
attack of general convulsions took place on the third day, after which 
there were delirium and coma alternately for several days, with coryza, 
angina, and offensive otorrhoea, lasting in all six weeks. The child re- 
covered, but remained deaf. 

In this form of the disease, therefore, the symptoms are of the most 
vinilent character. The onset is sudden. The child passes within a few 
hours from a state of apparent health, into one of the extreraest danger. 
Mo>t of the cases begin with violent fever, and great depression of the 
strength. The pulse »oon becomes very rapid (140, 150, 180), or so fre- 
quent that it cannot be counted, and it is at the same time small and often 
irregular. The skin is dry and burning hot in some parts, in others cool 
or even cold. There is generally nausea or vomiting, and these may be 
violent and constant. These are accompanied in some cases, but in our 
experience, only in the severest of all, by colli(pjative diarHuea and me- 
leorism. Delirium often exists from the first, or else there is drowsiness 
and dulness of intelligence, verging gradually in coma. In the most vio- 
lent cases, the 8tupf)r or coma alternate with convulsions, which may 
cause a fatal termination in eighteen, twenty-four, or thirty-six hours. 

When a case of this kind lasts over three, or even two days, the vio- 
lence of the nervous symptoms almost always subsides ; the convulsions 
cease to recur; the delirium is less violent; the coma gives way to drow- 
sineas, or the patient becomes again quite intelligent and observant ; the 



718 SCARLET FEVER. 

pulse often falls in frequency, and the heat of skin may diminish, and the 
eruption assume a more favorable appearance. All the symptoms seem, 
indeed, to be more promising, and very often both the physician and 
friends are greatly elated by the improvement in the patient's condition. 
Nor are these hopes always illusory, since children do recover occasionally 
even in cases that have exhibited the most threatening and malignant ap- 
pearance at the moment of invasion. It happens, unfortunately, however, 
in a majority of such attacks, that the improvement which takes place on 
the third or fourth day is only momentary. The nervous symptoms sub- 
side, but new phenomena make their appearance in the shape of severe 
inflammation, membranous deposit, and perhaps ulceration of the fauces, 
and extensive swelling and induration of the lymphatic glands and subcu- 
taneous tissues about the angles of the inferior jaw, and under the chin and 
throat. In connection with the throat-atfection which develops itself in 
this way, it is very common to have abundant purulent or membranous 
coryza, and often also otorrhoea. The symptoms assume, in fact, the fea- 
tures of the cases usually described under the title of scarlatina anginosa. 
As we shall, however, describe them directly in our account of the second 
set of grave cases, it is unnecessary to pursue the description at the present 
moment. We will state, however, before proceeding further, that the an- 
ginose and general symptoms which occur in cases beginning with violent 
nervous phenomena, and especially with convulsions, are nearly always of 
the most dangerous and malignant character, and usually end fatally in 
two, three, or four days after their appearance. 

The eruption in this class of cases varies according to the violence of 
the attack. In the severest one that we saw, that which proved fatal in 
fifteen hours, no eruption whatever was perceived, and we only knew it to 
be scarlatina by the character of the other symptoms, and by the fact that 
the sister of the boy had been sick in the same house with the disease fOr 
a week. In the case which terminated in twenty-four hours, the eruption 
showed itself in the form of scarlet patches about the face and upper parts 
of the body, twelve hours after the onset. In a third case the eruption 
was moderate, but perfectly well marked and general. In the other thir- 
teen cases, which lasted, with one exception, not less than three days, the 
eruption was perfectly well marked. It covered the whole surface, was at 
first scarlet in color, soon ran into a deep red, and then became violet or 
purplish. The exceptional case was one which lasted thirty-six hours, and 
proved fatal in that time. In this also, the eruption was well marked and 
extensive. M. Gueretin {Arch, de Med., t. i, p. 292, 1842), in his account 
of the acute malignant form which he witnessed, states that the eruption 
was nearly constant. In all our cases it occurred within twenty-four hours 
from the invasion, while in those of M. Gueretin, it appeared within twenty- 
four or forty-eight hours, or, as more frequently happened, not uutil the 
fourth or fifth day. 

If no favorable change takes place in these severe cases, and when they 
do not prove fatal at once, the patient grows weaker and weaker ; the de- 
lirium continues, or is replaced by coma; subsultus tendinum, rigidity of 
the limbs, spasmodic twitchings or general convulsions, make their appear- 



SYMPTOMS OF GRAVE CASES. 719 

ance ; the eruption becomes more and more livid ; the pulse grows smaller, 
more frequent, and irregular; the respiration is excessively embarrassed; 
deglutition becomes impossible ; and the patient dies in from three to 
seven or nine days. In some few instances, the child struggles on for 
several weeks, and dies in a state of utter exhaustion, or having a con- 
stitution of great powers of endurance, at last surmounts the disease and 
recovei*s. 

The invasion of grave cases is not always, as we have stated above, so 
violent as in those which have just been described. In rather more than 
two-thirds (4.'>) of the Gl grave case of which we have preserved notes, the 
onset was less threatening than in the other third, though the symptoms 
were severe and dangerous in most of these also, and when not so at the 
very start, very soon assumed the serious characters which make it neces- 
sary to class the cases in which they occurred as grave. The chief differ- 
ence between the symptoms that mark the onset of grave cases of this kind, 
and of those in which the symptoms are still more violent, which latter we 
have thus far been describing, lies in the character of the nervous phe- 
nomena — in the latter most severe, threatening, and dangerous, consisting 
of stupor, coma, or convulsions, and in the former, merely excessive agi- 
tation, restlessness, heaviness, or stupor. In one well-marked case of the 
kind now under consideration, the patient, a boy between seven and eight 
years old, was attacked in the evening with headache, fever, and vomiting. 
On the following morning a faint rash was perceptible, which, by the after- 
noon of that day, was distinct, though not very full. The case now rapidly 
assumed unpleasant features. The pulse rose to 150. There was much 
drowsiness and delirium, and on the fourth day constant picking at the 
l>ed-clothes and at the fingers. In another case, in a boy between four and 
five years old, the first sign of sickness was slight languor after dinner, 
which was followed by fever in the evening, and the development in the 
course of the night of a scarlatinous rash. On the following day, there 
was K)mc pain in the throat, with redness ; the pulse was 140, and the skin 
hot and dry ; there were no nervous symptoms, except slight drowsiness. 
On the third day the pulse was 136, the rash was well out, and there were 
no un|)]easant symptoms whatever. From this time, however, the symp- 
toms gnidually grew worse ; the throat-affection increasing, the cervical 
lymphatic glands becoming very much swelled, and the child growing 
more unea-y and restless, though retaining perfectly its intelligence. By 
the sixth day, the grave character of the case was fully developed, the 
eruption being intense, and of a deep brick-red, verging towards a purple 
color. There was at the same time very great drowsiness, al)undant dis- 
charges from the nasal pas-sages of thick sero-mucous and purulent fluiils, 
membranous exudation in the fauces, with gurgling and great difl[iculty in 
swallowing, and an utter lo.s8 of appetite. In a third case, a boy between 
one and two years old wa** a little fretful in the morning, and was seized 
in the evening with vomiting and fever, and very considerable restlessness. 
On the next day he was covered with a scarlet rash from head to foot, and 
the skin was fierj' hot. The pulse was IGO, regular, not large. The child 
was very drowsy, dozing nearly all the time, but quite intelligent when 



720 



;rlet fe" 



aroused. The fauces were intensely red and rough, and the tonsils much 
swelled ; there was very little external swelling. On the third day he was 
still very drowsy, and, when roused, less observant than before, though he 
still recognized persons. The pulse was 168, small, difficult to count, very 
hard and corded. The skin, especially that of the limbs, was scarlet, very 
hot, and dry ; the cutaneous capillary circulation was good. After this the 
symptoms grew rapidly worse ; the pulse continued at from 148 to 168 on 
the fourth and fifth days, and on the sixth rose to 172, at which it stood a 
few hours before death. On the fourth and fifth days, he was still very 
heavy and drowsy, and so much so on the former as to take no notice 
whatever except when moved. On the fifth day, an abundant sero- 
mucous discharge took place from the nostrils; the cervical lymphatic 
glands, which had begun to swell before, now increased in size ; there was 
some loud faucial gurgling, and the swallowing became difficult. On the 
morning of the sixth day, some of the symptoms improved so much as to 
flatter very greatly some of his attendants, who were unacquainted with 
the treacherous character of the disease. He roused up from his state of 
stupor, and noticed several things that were shown him, even taking them 
into his hand ; but the breathing continued bad, the lymphatic glands were 
swelling rapidly, and had already become very large, so that they formed 
great projections on either side of the neck. The pulse was 155, and small. 
In the middle of the day the breathing became difficult, from the internal 
and external swelling, and from the collection in the fauces of thick and 
viscid phlegm. The surface had now become pale. The tumefaction about 
the neck was immense. Down the front of the neck and along its sides to 
the clavicles, a kind of oedematous swelling of great size had come on, and 
was rapidly increasing. The pulse was 160, small and feeble. The legs 
and arms were of a dark, congested tint. Deglutition was excessively dif- 
ficult. In the evening the pulse was 172, and death took place just before 
midnight with slight convulsive movements. 

The mode of invasion is diflferent, therefore, in diflferent examples of the 
kind of grave cases now under consideration. In some it is even milder 
than in any of those that have just been detailed ; and it is not until the 
third, fourth, or fifth day, or even later, that the severity of the attack 
shows itself fully and unmistakably. 

After the disease is once established, it will be found upon examination 
that the fauces are of a deeper red color, and that they are more swelled, 
than in mild cases. At the same time there is more difficulty and pain in 
deglutition ; these are complained of by older children, and are shown in 
those who are younger by their refusal to swallow, by their crying upon 
making the attempt, and in some instances, especially at a later period of 
the sickness, by a positive inability to perform the movement. In nearly 
all of these cases, false membrane is formed upon the mucous membrane 
of the throat. This is never, or very rarely, present on the first day of the 
attack. In most cases it is not found until the second or third, and often 
not before the fifth or sixth day. MM. Rilliet and Barthez state that 
they have known it not to appear until the tenth and eleventh days. It 
appears first in small, thin, whitish, yellowish, or ash-colored points or 



SYMPTOMS OF GRAVE CASES. 721 

patches, on one or both tousils, or on the soft palate only, where it remains 
limited, or from whence it extends to the pharynx, which it may cover in 
whole or in part. The patches' are of variable thickness and consistence, 
and adhere sometimes very slightly, and sometimes with considerable 
tenacity to the mucous membrane beneath. They may remain for a day, 
and then be thrown off not to be again produced ; or they may form in 
several successive crops, until the case is terminated ; or, as most frequently 
happens, they last three or four days or more, and are then detached. The 
mucous membrane upon which they are seated is found in various condi- 
tions. It may present the redness and swelling indicative of severe in- 
flammation, or it may be softened, ulcerated, and, according to MM. Guer- 
sant and Blache, gangrenous, though as a general rule, what have been 
supposed to be sloughs are in fact portions of altered false membrane. 
There is more or less fetor of the breath, sometimes amounting to a gan- 
grenous odor, after the appearance of the pseudo-membrane. The severity 
of the symptoms is in proportion to the extent and thickness of the false 
membrane. 

"We have already seen that it is not uncommon to find ulcerations 
beneath the false membranes. In other cases of this kind the throat affec- 
tion assumes very great violence without the presence of any exudation 
whatever. In some the mucous membrane is of a deep red or even pur- 
plish hue, its consistence is softened, and it is swelled and covered with a 
layer of grayish or sanious pus. The tonsils are enlarged, infiltrated with 
pus, softened, and break down easily under the finger. In other cases, in 
addition to the redness and softening, ulcerations are present. These may 
be superficial, amounting only to erosions, or they may extend through the 
mucous, and even submucous tissue to the muscles beneath. They are 
seated generally in the pharynx, but may exist also on the tonsils, and in 
some rare cases they extend into the larynx. In still more malignant 
attacks of the disease, we find evidences of gangrene of the pharynx. It 
is important to distinguish between those in which the pseudo-membrane 
becomes so changed as to assume the appearance of sloughs, and those in 
which the tissues of the pharynx are really gangrenous. The former con- 
stitute by far the greater number of the cases which have been generally 
regarded as iihstances of gangrene of the throat. That gangrene of these 
ti-ssucj* docs actually occur in some few cases, is proved, however, by the 
evidence of Dr. Tweedie, who says {loc. cit., p. G50), that in malignant 
scarfatina "the membrane of the pharnyx is sometimes of a dark, livid 
color, and occasionally in a sloughing state," and by that of MM. Guer- 
sant and Blache, who state that they met with several instances of gan- 
grene of the phar)'ux in the p.seudo-membranou8 angina which prevailed 
in 1841. 

An almost constant accompaniment of cases of this kind is inflamma- 
tion and swelling of the submaxillar}' lymphatic glands and surrounding 
cellular ti.-sue. The tumefaction is generally confined at first to the glands 
beneath the jaw, which become painful to the touch. After a short time 
it extends to the parts behind the angle of the jaw, and beneath that 
bone, until at last the sides of the neck and the throat are largely dis- 

46 



722 SCARLET FEVER. 

tended, so as to interfere with, or even prevent in great measure, the open- 
ing of the mouth, and by the pressure exerted on the internal parts of the 
throat, to add to the difficulty of deglutition which already exists. In 
some cases the pressure is so considerable as to embarrass the respiration 
of the child. This swelling has been generally supposed to depend on in- 
flammation of the parotid glands ; but MM. Breton neau, Guersant and 
Blache, and Rilliet and Barthez, all state that parotitis is of exceedingly 
rare occurrence, and that the swelling in question depends nearly always 
on the causes just described. The last-named writers state, moreover, 
that the tumefaction of the cellular tissue is often of the nature of active 
oedema. The swelling of the cervical lymphatic glands, and of the cellu- 
lar tissue of the sides of the neck, and that under the throat and chin, 
seldom takes place to any considerable extent, according to our experience, 
prior to the third or fourth day. During the first two or three days, the 
chief symptoms are the fever, the eruption, and the nervous phenomena, 
which latter consists, in this class of cases, of either excessive agitation and 
restlessness, or of drowsiness or stupor. Very often, after a child has 
seemed to be very ill for two, three, or four days, from the violence of the 
febrile reaction and the severity of the nervous symptoms, it will appear 
to improve very decidedly on the third or fourth day, and elevate greatly 
the hopes of those interested in it. It is just at this time, however, that 
the throat affection is apt to set in severely ; and, moreover, it rarely fails 
to come in children who have presented violent symptoms during the first 
three days. The enlargement generally disappears, in favorable cases, in 
from three to twelve days, by resolution, while in others it terminates by 
suppuration of the glands and surrounding parts. 

In the form of the disease we are now considering, it is common to 
observe violent coryza, which may be either purulent or pseudo-membra- 
nous. It may appear from the very first, or not for several days after 
the eruption has commenced. The discharge is yellowish, granular, thin 
at first, and afterwards thick ; it contains often flakes and shreds of ex- 
udation, and becomes sometimes very offensive, and highly acrid, so as to 
excoriate very much the upper lip. It often flows in surprising quanti- 
ties, and generally continues up to the moment of death, or until all the 
symptoms have moderated. 

Otorrhoea is another symptom of this form. It generally occurs simul- 
taneously with coryza. The discharge is at first thin and watery, like 
that from the nostrils, but becomes gradually thicker as the case advances. 
The quantity is extremely variable. In some cases we have known it to 
fill the meatus and concha of each ear, and then to flow out and make 
large stains upon the pillow, or to collect very rapidly after being wiped 
away. It is, like the coryza, an unfavorable symptom, as it is a mark of 
the grave form of the disease, and because, if the child recovers, it is very 
apt to result in deafness, which is but too often permanent. 

These symptoms, coryza and otorrhoea, sometimes exist also in mild 
cases, but they do not then assume the peculiar characters which they 
present in grave cases. The discharges are much less abundant, and the 
mucus or pus is healthy, and scarcely oflensive to the smell ; they last but 



SYMPTOMS OF GRAVE CASES. 723 

a short time, and arc very rarely accompanied at the time or followed by 
more than a slight degree of deafness. 

The eruption is generally stated to appear later than in mild cases, and 
often to be less vivid and less extensive. It is also said to occupy only 
portions and not the whole of the body, to occur in irregular patches, or 
to appear and disappear alternately. This has not been the case in the 
instances which we have seen. In all but two of the forty-one, the erup- 
tion occurred early, generally within twenty-four hours from the onset. 
It was of a deep brick-red or livid color, and covered the whole surface. 
In one of the exceptional cases it did not take place until the seventh 
day, when it appeared in patches on the wrists and knees. On the eighth 
day, it extended to the rest of the extremities and abdomen, and on the 
ninth was general and of a rather dark hue. In the second exceptional 
case the eruption did not appear until the second day. It then came out 
over the whole trunk, and to a moderate extent upon the limbs also. In 
this, as in the previous one, it was dark in its tint. In three other cases it 
was quite moderate in amount, but general and well-marked. 

The general sipiipfoms are more severe in grave than in mild cases. It 
sometimes happens that for one or two days, or even longer, the case 
promises to be mild, but then suddenly assumes the threatening features 
of the form under consideration. The fever is usually intense, the pulse 
being full and strong, and rising very soon after the onset to 140, 150, or 
170; the skin is very hot and dry; there is more restlessness and irrita- 
bility than in the mild form, and after one, two, or three days, appears a 
strong disposition to delirium and stupor, not unfrequently merging into 
coma. The respiration is accelerated, and in many instances, owing to 
the throat-affection, labored and difficult. In most of the cases, a loud 
gurgling, which is very characteristic, is heard in the throat, particularly 
when the child is asleep or dozing. This depends in part upon the col- 
lection of viscid and tenacious secretions in the fauces, — which sometimes 
embarrass the respiration so much as to make it necessary to remove them 
with a mop, — and in part upon the existence of the coryza of which we 
have spokeD. The coryza is a symptom of very serious consequence at 
all ages, but especially in young children. There is generally some cough, 
which may be frequent and troublesome, though not usually so unless 
there be a disposition to laryngeal complication. The voice is hoarse, 
guttural, and sometimes whispering. When the cough is very frequent, 
and still more, when it becomes hoarse and croupal, in connection with 
] f- • or whi.«pering voice, or aphonia, there is great reason to fear the 
. \' -ion of the exudation into the larynx, which constitutes an almost 
ii» '^' -arily fatal accident. The face is deeply flu.shed at first, and the ex- 
pre?v»ion anxiou.s. If no improvement take place, the case as.«ume8 in four 
or 6ve days, or even less, a .«till more threatening aspect. The pulse be- 
comes ver}' rapid and small; the restles.sness and delirium pass into 
drowsiness or coma ; the tongue becomes brown and dry; the teeth are 
covered with sordcs; the lips are dry, cracked, and bleeding; diarrhnea 
is apt to occur; and the patient dies in from three to ten days, in a well- 
marked typhous condition. In other instances, on the contrary, the case 



724 SCARLET FEVER. 

runs on from week to week, and at last, after an illness of four, five, or 
six weeks, the child either dies or recovers after all chances for life seem 
to have been lost. 

In order to show, in their natural connection, the different symptoms 
that have just been described, we will cite the following abstract of three 
of our cases. The first occurred in a boy between seven and eight years 
old. On the fourth day of the attack the pulse was at 150, and the fauces 
presented flakes of false membrane. The fauces were very much swelled, 
and deglutition became difficult; faucial gurgling came on, and the throat 
was filled with viscid and tenacious secretions. The nasal passages now 
became occluded by constant discharges, at first mucous and then muco- 
purulent, with admixture of membranous particles. From the fifth to the 
ninth day there was an excessive fetor from the nose and mouth. The 
lymphatic ganglions just beneath the ear swelled very greatly, so as to ex- 
tend much beyond the line of the inferior maxilla. The tongue and lips 
became dry and cracked, the teeth were covered with sordes, and the 
angles of the eyelids inflamed and then ulcerated. On the sixth, seventh, 
eighth, and ninth days, there were taken away from the mouth and throat 
of the child, with a mop, hard and most offensive masses of dried-up 
mucus and incrusted epithelium, enveloped in thick, gluey, dark-colored 
mucus. These masses stuck to the fauces, tongue, and lips, so tenaciously, 
that they could be removed only by means of a mop, the boy himself 
being quite unable to detach them. On the seventh, eighth, and ninth 
days, though the cervical lymphatic glands were very much swelled, the 
patient was better. The pulse came down gradually from 152 to 132, 
128, and 112, and the swallowing improved so much that the child could 
take liquids with less convulsive effort, and could drink continuously. 
The drowsiness diminished, and the delirium ceased. On the eighth day 
a slight erythematous redness appeared on the bridge of the nose, and ex- 
tended towards the malar bones. The skin of the face and eyelids be- 
came somewhat swollen and puffed by an oederaatous effusion. On the 
ninth day the pulse was down to 104, and the skin was nearly natural as 
to temperature. The swelling was very great on both sides of the neck, 
and the glands on the right side were red on the surface, very hard, and 
quite painful. The swallowing was much easier for drinks, but as yet no 
solid, not even of the softest kind, could be taken. On the fourteenth 
day from the onset we opened a very large abscess on the left side of the 
neck, which discharged abundantly a healthy and laudable pus. On the 
fifteenth day we opened a still larger abscess on the right side, and, after 
this, perfect recovery took place. 

In another example, which has been alluded to already, occurring in a 
boy between four and five years old, the gravity of the case did not show 
itself clearly until the sixth day. On the evening of that day the pulse 
was 128, the skin very hot and dry, and there was an intense eruption of a 
brick-red color. There was, at the same time, great drowsiness, and utter 
loss of appetite. Deglutition was difficult, and there was a loud faucial 
gurgling during sleep. There was now also a considerable amount of 
membranous exudation in the fauces. During the seventh and eighth 



SYMPTOMS OF GRAVE CASES. 725 

days, the boy continued very sick. He was drowsy, almost comatose ; the 
eyes were half open and the conjunctiva? minutely injected ; there was an 
abundant coryza, the discharges being composed of offensive mucous and 
sero-mucous fluid, with an admixture of pus and of flocculent or grumous 
particles, the latter consisting evidently of broken-down membranous 
exudation. There was no otorrha?a. The pulse rose from 120 to 128. 
During the night of the seventh day the anginose affection was so severe 
that the child could swallow nothing from 10 p.m. to 3 a.m. ; fluids poured 
into the mouth ran out again in part, and were in part returned through 
the nostrils. On the tenth day there was still no decided improvement, 
except that the pulse had fallen to 112. The coryza continued as before ; 
the fauces were covered thickly with whitish exudation ; the deglutition 
was a little easier. The drowsiness continued, as the child dozed nearly 
all the time, merely rousing from time to time to take drinks, and then, 
in spite of all solicitation, sinking into sleep again. The abdomen was 
tympanitic. The urine was rather free, more so than it had been before, 
and it was also clearer and of a lighter color. By the twelfth day there 
was a decided improvement ; the pulse had fallen to 106, and the child was 
not quite so heavy. The act of swallowing was easier, and the fauces 
showed less of the plastic exudation, but they were still very much coated 
with tenacious mucus. On the thirteenth and fourteenth days the patient 
continued to mend. The pulse fell to 98 and 92 ; the fauces had become 
clear of the exudation, and presented instead an excoriated and ulcerated 
appearance. The secretions into the fauces were less viscid and less copious. 
The coryza had diminished, and the discharges had become first muco- 
purulent and then mucous. The drowsiness had diminished, so that he 
wake<l spontaneously and began to ask for his toys. He now began to 
demand food, but refused to eat when things were brought to him. On 
the fifteenth day he was extremely irritable, screaming most violently for 
the slightest causes. On the sixteenth day the pulse was 92, and the skin 
nearly natural as to temperature. He was now exceedingly emaciated 
and very weak. The orifices of the nasal passages were very much 
irritated and incrusted, but there was scarcely any coryza. The tongue 
was clean, pink in color, and moist, the thirst not too great, and there was 
a little appetite. The temper was improving. From this time forward 
the child improved .steadily but slowly, so that he sat up for the first time 
on the twenty-seventh day. He was as much emaciated at that time as 
after violent typhoid fever. 

Tli» reader must not, however, suppose that all grave ca>e8 present 
liir i.'hout their whole course, symptoms so dangerous as those which 
marked the two examples that have just been detailed. In some, on the 
contrary, the symptoms, though of such a character as to deserve and re- 
quire the title of grave, are of a much milder kind. In order to make 
this part of our description of the disease as clear as may be, we will relate 
the following as an example of a grave case in which the symptoms, though 
severe, were neither malignant, nor at any one time very dangerous to life. 
A girl between seven and eight years old waa well at breakfast. In the 
coarse of the morning she complained of sore throat, and of not feeling 



726 



FEVER. 



well, and at 4 p.m., when we saw her, was quite feverish, with a frequent pulse 
and hot skin, and showed already a well-marked but rather faint scarlet 
rash upon the trunk of the body, and about the elbows. On the following 
day the trunk and upper parts of the limbs were covered thickly with an 
intense eruption, of a bright scarlet color. The fauces were very red, 
somewhat roughened and a good deal swelled. The only nervous symp- 
tom present was severe frontal headache. There was no unusual agitation, 
no drowsiness, and nothing like convulsive movement. On the evening of 
this day, the pulse had run up to 168, and was rather full, but not hard. 
The skin was exceedingly hot and burning ; during the night there was 
great restlessness, and the child was wakeful and occasionally delirious. 
On the third day the symptoms continued much the same, except that the 
pulse was down in the morning to 152, that the rash had extended to the 
hands and feet, and that some small spots of whitish exudation were now 
visible on each tonsil. On the night of this day the fever again increased 
very much, and the child was again delirious. On the fourth day the 
pulse was 148 ; the exudation had increased so much as to cover a good 
portion of both tonsils, and it had extended also in a slight degree to the 
posterior wall of the pharynx. There was now a considerable enlarge- 
ment of the lymphatic glands situated at the angle of the jaw on the left 
side, and a smaller one on the right side. Deglutition was somewhat 
painful, and a little difficult, but not seriously so. The case continued in 
much the same way until the seventh day, when the pulse had fallen to 
132, and the eruption had faded very much on the trunk of the body, and, 
to a considerable extent, upon the limbs also. The fauces now exhibited 
the false membrane over the whole of both tonsils, over the half-arches, 
the sides of the uvula, and upon the upper portion of the posterior wall of 
the pharynx. Instead of being whitish and clean-looking as at first, how- 
ever, the false membranes now looked exactly like sloughing portions of 
the mucous membrane. They were of a dirty brown color, softened, and 
seemed to be detaching themselves like sloughs from the tissues beneath. 
On the ninth day the patient was much better, the pulse having fallen to 
116; the eruption had almost wholly disappeared; the heat of skin was 
very much reduced ; the dark-colored portions of false membrane had dis- 
appeared from the fauces, leaving the mucous membrane beneath red, 
excoriated, and in parts ulcerated. On the thirteenth day, the child was 
convalescent, the pulse having fallen to 96, the heat of skin having disap- 
peared, and the throat being nearly well. The appetite had returned, the 
temper was serene and cheerful, and the patient was, in fact, well, with the 
exception of weakness, and some remaining soreness of the throat. 

Laryngitis has been supposed by some persons to be of frequent occur- 
rence in the course of the disease", while others assert that it rarely, if ever, 
occurs. M. Bretonneau has never met with it. M. Rayer says he does not 
know that the exudation has ever been found in the larynx or trachea. 
Tweedie {Cyclop. Pract Med., Art. Scarlatina, p. 640) states that in the 
dissections he has made he has not seen an instance of the membranous 
exudation extending into the larynx. That it does sometimes occur, is 
proved nevertheless, beyond a doubt, by the evidence of MM. Guersant 



SYMPTOMS OF GRAVE CASES. 727 

and Blache, Rilliet aud Barthez, and others, and by our own observation. 
MM. Rilliet and Barthez report three eases in whieh it was found in the 
larynx atier deatli. These gentlemen state, however, that they have never 
observed the peeuliar symptoms of croup. This does not accord with our 
own experience ; for in several cases that we have seen, all the peculiar 
symptoms of that malady were present during life. The subject of one of 
these cases was a boy two years of age. A few days after the invasion of 
the disease, a severe and extensive pseudo-membranous angina was devel- 
oped. This was soon followed by all the symptoms of croup — hoarse 
cough, stridulous respiration, weak, feeble cry, dyspna*a, and wliispering 
voice, which lasted about five days, when the angina and croupal symp- 
toms both diminished very much, and the child seemed in a fair way to 
recover : suddenly, however, extensive tumefaction of one side of the neck 
took place, and he died in twenty-four hours. Unfortunately no examina- 
tion couKl be made. In another case, in a child between six and seven 
years old, who had a most violent attack of the disease, severe croupal 
symptoms set in on the eighth day. They consisted of harsh, croupal 
cough, stridulous respiration, and great difficulty in swallowing, and the 
act of swallowing occasioned much harsh cough and strangling. The 
symptoms continued on the ninth day, after which they moderated, and 
the child finally recovered entirely. In a third case, also a violent one, 
in a boy between eight and nine years old, and in which general convul- 
sions occurred on the first and second days, the symptoms had improved a 
good deal on the third or fourth day. On the fifth day he was not so well, 
being more restless and heavy, and having much difficulty in breathing, 
with some croupiness of sound. These symptoms increased rapidly until 
they gave rise to most violent fits of suffocation, and caused a fatal termi- 
nation on the sixth day. In a fourth case, in a child nine months old, 
death occurred on the thirteenth day from laryngitis, occurring in connec- 
tion with membranous angina. The fatal termination was preceded by 
hard, dr}-, and croupal cough, stridulous respiration, and great diffirulty of 
deglutition. In a fifth, in a child under a year old, croupal symptoms 
made their appearance on the sixth day, the fauces being at that time 
covered with membranous exudation, and they caused or assisted to cause 
a fatal termination on the eighth day. In yet another case, the subject of 
which wa** between one and two years old, a grave attack of scarlet fever 
was entirely recovered from. At the end of the second week the child 
wa.« seized, owing to improper exposure in a cold house, against which the 
parent>< had been properly warned, with anasarca. This also was recovered 
from, and again the parents were warned against improper exposure. On 
the vent* day after our last visit, however, the child was taken down stairs 
into a nyftm with the windows open, and this on a mild day in the month 
of February. The child was seized now with di[»htheritic angina, and 
died, after a few days, of croup. This was in the fourth week from the 
on.«€t of the scarlet fewer. In a seventh case, severe from the beginning, 
the patient recovered so as to be apparently out of danger, but, owing to 
the rr>om being very cold from the fact that it was large, with wide rat- 
tling windows down to the 6oor, aud from the fire being too small, the child 



728 SCARLET FEVER. 

took cold, and, at the end of the third week, was seized with severe croup, 
which had many of the features of membranous croup, but which was, in 
all probability, spasmodic croup, dependent on ulcerative laryngitis. The 
case -continued seven days, during which time the patient was violently ill, 
but finally, after a most dangerous struggle, it ended favorably. 

The symptoms which indicate a disposition to implication of the larynx 
are frequent, hoarse, and croupal cough, hoarse and whispering voice or 
cry, aphonia, and dyspnoea with stridulous respiration. 

The duration of grave cases of scarlet fever is very uncertain. In some 
the disease runs its course with frightful rapidity, destroying life within a 
few hours or days. In others, though the symptoms of the early stage may 
seem to be as violent as in those where death occurs in a very short space 
of time, the patient either lingers for several days or two or three weeks, 
and then dies, worn out by the violence or malignancy of the attack, or 
else, after a most dangerous and apparently desperate illness, he finally 
struggles through and recovers. 

In the most violent of the grave cases, those which we described first as 
forming a separate group, 18 in number, of which 13 proved fatal, the du- 
ration in the fatal cases was between eighteen hours and six days. Of the 
13, 2 proved fatal in eighteen hours, 1 in twenty-four hours, 2 in thirty-six 
hours, 4 in three days, 1 in four days, 1 in five days, and 2 in six days. Of 
the 5 favorable cases, 1 lasted three weeks, 1 four weeks, 2 six weeks, and 
1 two months. 

Of the less violent of the grave cases, 43 in number, 15 died, and 28 
recovered. Of the 15 fatal cases, 1 died in four days, 2 in five days, 2 in 
seven days, 3 in eight days, 2 in thirteen days, 1 in fourteen days, 1 in fif- 
teen days, 2 in four weeks, and 1 in five weeks. Of the 28 favorable cases, 
the duration of the shortest was seven days. The remainder lasted from 
twelve days to six weeks, the most common period being between three and 
four weeks. 

Complications and Sequelae. — Dropsy. — This is one of the most fre- 
quent and important sequelae of the disease. We have already remarked 
that in a considerable proportion of cases, the exact number apparently 
varying somewhat in different epidemics, the urine becomes albuminous 
during the stage of desquamation. This, however, is usually transitory, 
and probably depends partly on the condition of the blood itself, and 
partly on renal congestion. But in some cases, owing to one of the causes 
to be mentioned hereafter, the albuminuria persists, or if it has not been 
present or has disappeared, again makes its appearance ; and the symptoms 
of acute nephritis develop themselves. Among these the most striking one 
is dropsy, and, indeed, so prominent is it, as to have alone attracted atten- 
tion for a long time, and only to have comparatively lately been associated 
with a lesion of the kidneys. 

Certainly, in the vast majority of cases, when dropsy appears as a sequel 
to scarlatina, the urine will be found to present all the characters present 
in acute Bright's disease ; and yet there are some high authorities (Simon, 
Becquerel, Philippe, Eayer) who assert that marked dropsy may occur 
without the slightest albuminuria. It is possible that some of these cases 



1 



SEQUELS — DROPSY. 729 

raay be explicable by the fact that the urine has only been occasionally 
examined, and that albumen may have been temporarily present but have 
been overlooked ; but it at present seems undeniable, that, in some instances 
also, dropsy may appear without any abnormal condition of the urine what- 
ever. It is probable that, in these cases, the dropsy depends upon an anirmic 
state of the blood, developed during the course of the disease. 

The frequency with which dropsy is developed, varies greatly in differ- 
ent epidemics and in different forms of scarlatina. It occurred in a fifth 
of the cases of MM. Rilliet and Barthez, and in 31 of the 274, or in about 
8 ninth, of those observed by ourselves of which we have kept notes. It 
occurs generally in the course of the second or third week of the* disease, 
and during the process of desquamation. It is thought to follow cases of 
moderate severity much more frequently than those of a grave character. 
Dr. Tweedie states that it has never been observed to succeed a malignant 
attack. This does not, however, accord with our own experience, since of 
the 31 examples that we have seen, 8 occurred in grave cases of the disease. 
Still it may be said on the whole, that the susceptibility to renal disease 
bears an inverse proportion to the activity and complete development of 
the symptoms of scarlatina. The efiusion may attack any one of the cavi- 
ties or the cellular tissue of the body, or all at once. The most common 
form in which it appears is anasarca, afler which the most frequent are, in 
the order in which they are mentioned, wdema of the lung, hydrothorax, 
ascites, and hydropericardium. 

The exciting cause of the dropsy is generally believed to be cold, con- 
tracted usually by exposure to air and moisture at too early a period. 
We have rarely known it to occur when the patient has been confined to 
the chamber or house until after the twenty-first day ; while, on the other 
hand, we have seen it to follow immediately upon a ride in cool weather on 
the fourteenth day, the child having apparently been convalescent for seve- 
ral days before. We have known it to occu^/'also when the child has been 
allowed to run through the house exposed \/) draughts from open doors and 
Windows. 

We have been able, in a number of instances, to trace it directly and 
obviously to cold. Thus, in one very marked example, a boy between six 
and geven years old had had a mild attack of the disease, and was so en- 
tirely recovered that we ceased our visits on the tenth day, leaving strict 
injanctions with the mother as to the necessity of confining the child to 
the house for at least ten days longer. On the fourteenth day, he was al- 
lowed to sit for fiflecn minutes, late in the afternoon of a cool April day, 
on the marble front-door step. He was seized that night with fever and 
vomiting, had anasarca next day, and, during an illness of two weeks, had 
dropsy of the pericardium, effusion into the right pleural sac, ascites, and 
gome figns of uraemia. In another case, a boy eleven years old had recov- 
ered entirely of a mild attafk. He slept in a room heated by a stove. On 
the nineteenth day, the weather being cold, he got up early in the morning 
to light the fire, which had gone out accidentally. He was attacked that 
day with bronchitw, and was, on the following day, anasarcous. In another 
instance, anasarca was produced at the end of the third week, the child 



730 SCARLET FEVER. 

being quite well previously, by his being taken into a cold room to sleep. 
"VVe could cite other instances of the same kind, but these are enough. It 
is sufficient to say that in a large majority of the cases that we have seen, 
it has manifestly and obviously followed improper exposure during the 
second or third week. In a few cases, however, it has come on without any 
imprudence whatever, and we have been entirely unable to ascertain the 
cause. 

Nor can it yet be asserted positively that the action of cold will fre- 
quently cause dropsy unless the urine have been previously albuminous : 
although it is undoubted that when albuminuria is present, any imprudent 
exposure will insure the occurrence of dropsy. 

We are in the habit now of always directing the mother or nurse to 
keep the patient confined to the chamber for four weeks from the onset 
of the disease, or, if it be allowed to run through the house, to take care 
to have it well clothed, and to keep the windows and doors carefully 
closed should the weather be cold or cloudy. This direction is one of 
the most important to be given in the course of the disease. It ought to 
be insisted upon in all and every case, occurring in the cool season of the 
year. 

The question was formerly much discussed, whether the condition of 
the kidney which accompanies scarlatinal dropsy was one of the forms of 
renal disease known as Bright's disease. Dr. Johnson suggested that it 
was a peculiar affection of these organs, characterized by a desquamation 
of the epithelium of the tubules, for which he proposed the name of des- 
quamative nephritis. Recent observations have, however, shown that 
there is in reality nothing specific in the lesion, but that it is identical 
with other cases of renal catarrh or tubal nephritis, to use the excellent 
name bestowed by Dickinson, occurring from whatsoever cause. Indeed, 
it may be said that in almost 75 per cent, of all cases of chronic renal 
disease in children, the cause of the affection has been scarlatina, and the 
form of the lesion is that which we have above mentioned. 

Various causes have been assigned for the frequent development of tubal 
nephritis in the course of scarlatina. Thus it has been supposed that the 
affection of the kidneys resulted from inaction of the skin, owing to the 
intense congestion which attends the eruption ; but clinical experience 
shows that it is precisely in the cases where the affection of the skin is 
most intense that the kidneys are least disposed to disease. It would 
rather appear that when the action of the virus is not fully determined to 
the surface, there is violent congestion of the kidneys established, which, 
especially when the patient is exposed to the action of cold, may result 
in the development of tubal nephritis. 

Morbid Anatomy of the Kidneys. — When death occurs in the acute stage 
of the renal disease, the kidneys are found enlarged and very heavy. The 
surface is smooth and injected ; on section, the organ drips with blood ; 
the Malpighian bodies are congested, and appear as red dots; and the 
vessels of the cortex and cones are gorged with blood. The tubules are 
distended with granular epithelium, granular matter, or fibrinous plugs. 
The cortex appears coarse-grained, and presents intermingled dots or 



SEQUELS — DROPSY. 731 

Streaks of red and buff color. In the more chronic form of the disease, 
the kidney is also much enlarged and very heavy; its surface smooth, 
and pale, or dotted with congested stellate vessels. The capsule is not 
thickened, and is readily removed. On section, very little blood escapes; 
the cones retain their pinkish or red color ; while the cortex is coarse- 
grained, thickened, and of a peculiar opaque white color. The Malpighian 
bodies may be distended, owing to obstruction to the escape of the blood. 
The principal lesion, however, is still found within the tubules, which are 
stuffed with epithelial cells, or with granular matter resulting from their 
disintegration ; occasionally, clear fibrinous plugs are also seen occupying 
their calibre. It frequently happens that the epithelium undergoes fatty 
degeneration, and when this is marked, the cortex acquires a yellowish 
tint. According to Dickinson, there is less tendency to this change in 
cases of tubal nephritis following scarlatina than after other causes ; a 
circumstance which he thinks may possibly account for the comparatively 
curable nature of scarlatinal dropsy. 

The drop.?ical sifmptoms usually show themselves in the third or fourth 
week of the disease, and are generally preceded for a few days by albu- 
minuria. In most of the cases that we have seen they occurred in the 
third week, but they sometimes appear at the end of the second, and 
sometimes not until the fourth week. In one case they showed themselves 
first on the thirtieth day, after the child had been exposed to too cool a 
temperature in an insufficiently warmed room. They occur, therefore, as 
a general rule, during the stage of desquamation. The attack is some- 
times very sudden, but in most instances it is slow and gradual. The 
effusion is not commonly the first symptom observed. On the contrary, 
the dropsy is almost always preceded for one or two days by the signs of 
a more or less considerable constitutional disturbance. The patient has 
usually passed safely through the eruptive stage of the fever, and has been 
considered for several days as convalescent, for, as we have already re- 
marked, the dropsical affection is much more rare after grave than after 
mild cases. The child has perhaps been running about the house, or it 
has even been out, the parents supposing, unless warned by the physician, 
from the disappearance of the fever and other symptoms of illness, and 
from the return of appetite and gayety, that complete recovery has taken 
place. But, either after some exposure, or sometimes without any appre- 
ciable cause, the child becomes drooping, languid, and irritable, or uneasy, 
peevish, and restless. Simultaneously with or very soon after these symp- 
toms, fever sets in ; the skin becomes dry and heated, and there is usually 
aD elevation of the temperature to the extent of 4° or 5°; the pulse is 
fre<juent and hard, or it is frequent and jerking; the appetite is dimin- 
ished or lost, and there is more or less thirst ; the Ijowels are generally 
constipated; the urine is usually diminished; and there is not unfrequently 
gome nau.«ea or vomiting, and complaints of headache. 

The symptoms which precede the ap[)earance of the effusion are not 
always, however, so marked, while in other instances they are scarcely 
noticeable, and yet the effusion may take place suddenly, and, affecting 



732 



'EVER. 



the subcutaneous cellular tissue and different internal organs simulta- 
neousl}^, may cause a fatal termination with frightful rapidity. 

The effusion usually commences in the face, which becomes slightly 
swollen. The amount of the effusion is sometimes very slight, leaving us 
in doubt even whether there is really any or not. The swelling is most 
marked about the eyelids, which look puffed, and it may be confined 
entirely to them, or, at least, it may be only in them that we can feel sure 
of its existence. From the face it extends to the hands and feet, and 
either remains limited to these parts, or spreads over the whole surface, 
and gradually or rapidly to the internal organs. The skin over the parts 
in which the effusion has taken place is firm, hard, and elastic to the 
touch ; it does not generally pit, at least not in the early stage, and it is of 
a dull white color. 

In very mild cases the constitutional disturbance is usually but slight, 
and the effusion may be so small in such instances, as to leave us in doubt 
as to the cause of the sickness. Generally, however, we have been able 
to determine the cause of the fever by a careful examination of the face, 
and particularly of the eyelids, which look a little swelled and distended, 
and by the presence of a slight puffiness or cushiony appearance of the 
backs of the hands and feet. In such cases the general symptoms usually 
pass away after a few days ; the urinary secretion, which had been dimin- 
ished in quantity and of a deeper color than natural, becomes again 
healthy ; the anasarca disappears, and the child returns to its ordinary 
condition. In more severe cases the general symptoms are all more 
marked ; the anasarca is more extensive and the swelling more consider- 
able ; the child, if old enough to describe its sensations, complains of pain 
in the back, and the lumbar region is tender to the touch ; the urine ex- 
hibits much more marked changes in its character ; but still, unless some 
important internal cavity be attacked, the symptoms diminish after a 
week or ten days, and the child recovers gradually. In still more violent 
cases, the amount of the effusion is very large indeed, the face is disfigured 
by the swelling, the limbs are largely distended, the cellular tissue of the 
trunk of the body is infiltrated, the quantity of urine discharged is very 
small or the secretion is arrested entirely for one or several days, and the 
fever is high. If the disease is not removed, the effusion may extend to 
the internal organs : to the lung, producing oedema of that organ, to the 
pleural sac, causing hydrothorax, to the pericardium, to the peritoneal 
cavity, or to the brain. Death may occur in these violent cases from 
asphyxia occasioned by oedema of the lung, by hydrothorax, or by the 
obstacle to the circulation caused by the presence of the effusion in the 
pericardium ; from hydrocephalus, or, finally, the patient may sink into a 
comatose state like that which often precedes the fatal termination of 
Bright's disease in the adult, and due, like that, to ursemia. 

It sometimes happens, as was stated above, that death occurs with very 
great rapidity. MM. Guersant and Blache have known it to end fatally 
in twelve, fourteen, and thirty-six hours. In a case that came under 
our own observation in consultation, a child between one and two years 
old, who had had a very mild attack of scarlet fever, was seized suddenly 



SEQUEL.E — URINE. 733 

towards the end of the third week, after it was supposed to be quite well, 
and after exposure to draughts of cold air iu tlie lower room of a small 
house, with vomiting, and i?hortly afterwards with convulsions and coma, 
which terminated fatally in thirty-six hours. In another case, in a boy 
Wtween thirteen and fourteen years old, who had had a mild but well- 
marked attack, and who had convalesced, and been out of bed for a few 
days, fever with slight headache, and diminution of the urine, came on at 
the end of the second week. After two days of slight ailment, without 
any signs of anasarca, he suddenly without any warning, fell into violent 
convulsions, which were repeated frequently, with lulls of imperfect con- 
sciousness, for a few hours. After twelve hours he became completely 
comatose, with occasional convulsive seizures, and died at the end of eight 
hours more. 

According to Gee (Joe. cit.), urajmic convulsions and coma are not fre- 
quent iu the course of scarlatinal dropsy, nor are they of such fatal import 
as in acute Bright's disease in the adult. 

The symptoms which mark the occurrence of internal effusion will de- 
pend of course upon the part attacked. In one case they will be those of 
OKlema of the lung, in another those of hydrothorax, and in another those 
of hydropericardium or ascites. 

'Urine. — The particular condition of the urinary function is next to be 
described. It has already been stated that the amount of urine secreted 
is less than natural during the early period of the dropsical attack. But, 
while this is true, it ought to be observed that the patient often voids the 
secretion more frequently than usual. There is in fact micturition, a symp- 
tom occasioned no doubt by the irritating character of the uriue, which 
causes the bladder to contract and expel that fluid so soon as even a small 
quantity collects. The diminution in the amount of the secretion is usu- 
ally a very marked symptom. It is sometimes almost or even entirely 
uuppreKsed for a considerable period. In one case that occurred to one of 
ourselves, in a boy between one and two years old, there was no discharge 
whatever for a periord of thirty-six hours. During this time there was 
DO d'.-»leDsion of the bladder, as we ascertained this point by careful pal- 
pation and percussion. In another ca,se, which occurred in a girl between 
three and four years old, and who wa.s nursed by the grandmother, one of 
the most accurate, reliable, and experienced nurses in the city, we were 
assured that there was no discharge whatever of urine for five days in suc- 
cewion. During this suppression there was no accumulation in the blad- 
der. C)n the contrary, the hypogastric region was flat, depressil)le, and 
sonorous on percussion. The patient waa very ill during all this time. 
She was feverish and passed nearly the whole time in a semi-comatose 
state, but could be rou.sed with much effort, so a» to show some intelli- 
gence; she rejected by vomitiDg almost everything that was given her, 
and complained when aroused of severe headache. 8he had no convul- 
sion.<i nor any convulsive movemenU«, and finally recovered as the kidneys 
regained gradually their secretory function. In many other cases that 
have come under our observation, especially those which we have seen in 
latter years, when we have watched this symptom more carefully, the 



734 SCARLET FEVER. 

diminution of the urine has been very great, so much so as to constitute a 
most marked and reliable symptom. 

In mild cases, when the diminution is not very marked, the urine is 
of a deeper color than natural, but retains its transparency when first 
voided. It is apt, however, to become turbid on cooling, and to deposit a 
more or less abundant precipitate of urates. Its reaction is acid ; its specific 
gravity increased in proportion to the concentration ; and urea and the 
chlorides are much diminished. Albumen is present, and microscopic ex- 
amination shows epithelial or hyaline casts of the renal tubules, renal 
epithelium, and blood-globules. In more severe cases, the urine is very 
much diminished in quantity, the color is either a very dark red, or has a 
blackish or brownish tint, or is like smoke or soot ; the specific gravity is 
very high ; the amount of albumen large, and the precipitate contains 
many casts and blood-globules, mixed with abundant urates. 

The amounts of albumen and blood bear no definite relation to each 
other ; in some cases, the albumen may be abundant without any blood 
being present; while in other cases, with a large precipitate of blood- 
globules, the urine may contain but a moderate amount of albumen. 

Basham calls attention to the occasional development of a bluish-green, 
and subsequently greenish-black color, on the addition of nitric acid to the 
heated urine, as a sign of very grave augury, being associated with expen- 
sive and advanced renal disease. 

The duration of this stage of diminution of urine varies greatly in dif- 
ferent instances, and is, to a certain extent, indicative of the future prog- 
ress of the case. It is succeeded by a stage in which the urine becomes 
abundant, even exceeding the normal amount, the specific gravity falls, 
and the urea and chlorides return to the normal figure, but albumen is 
still present, the smoky color is apt to persist, and the precipitate which 
forms on standing contains renal epithelium, blood-globules, and granular 
or epithelial casts. 

In favorable cases, the smokiness and albumen now gradually disap- 
pear, the urine often continuing for a little while to be secreted in exces- 
sive quantity ; but in other cases, and unfortunately they are but too fre- 
quent, the albumen persists, and the urine assumes the characters indicative 
of chronic Bright's disease. 

The form which the dropsy takes varies greatly in difierent cases, and 
seems to depend on inappreciable causes. Of the 29 cases that w^e have 
met with, in which its distribution was noted, anasarca alone was present 
in 22. In 1, there was extensive anasarca, hydrothorax of the right side, 
hydropericardium, and ascites. In 5, grave cerebral symptoms, probably 
ursemic in character, were present ; and in 4 of these anasarca also existed. 
In 1 there were also hydrocephaloid symptoms, but of much less violent 
form. 

Recent researches have established the fact that most of the cases for- 
merly regarded as acute hydrocephalus are in reality due to the poisoned 
state of the blood, the so-called uraemia, so familiar to all, that it is merely 
necessary to allude to it in this place. 

The degree of danger to be apprehended from this dropsical complica- 



SEQUELAE — DIARRHCEA. 735 

tion depends npon the form which it assumes. M. Cazenave {loc. cit., p. 52) 
says that there is no danger from it so long as it remains confined to the 
subcutaneous celhdar tissue; and this is probably true. When, however, 
it attacks the serous cavities, or becomes associated with cerebral symp- 
toms, due to the retention of urea and other excrementitious matters in 
the system, it is exceedingly dangerous. Dr. Wood {Pract. of Med., vol. i, 
p. 403) says that he has seen but one latal case of scarlatinal dropsy, and 
in that the heart was diseased. Of the 29 cases that we have had under 
charge of which we have preserved notes, 6 were fatal. Of the 22 cases in 
which the effusion was anasarcous alone, but 1 was fatal. All of the 5 in 
which well-marked hydrocephaloid symptoms, due to ura^uia, occurred in 
connection with anasarca, ended fatally. In one other case, which ended 
favorably, there were mild uremic symptoms present. In the case above 
adverted to, in which hydrothorax, hydropericardium, and ascites were 
added to the anasarca, the patient recovered after a long and severe illness. 

In addition to the cases of dropsy and ura}mia just referred to, and which 
all occurred in our own practice, we have seen quite numerous examples of 
scarlatinous dropsy with ura^mic symptoms in consultation or in hospital 
practice. In one instance, uriemic symptoms came on very suddenly in a 
young child, and proved fatal in thirty-six hours, while in other cases, 
theV have run a more gradual course, either ending fatally or terminating 
favorably after a severe illness of from several days to several weeks. In 
one case where recovery followed, the patient, a girl, between three and 
four years old, was in a semi-comatose state for a week, with fever, exces- 
sive irritability of the stomach, and complaints of headache. For a period 
of five days the urine was entirely suppressed, not a drop having been 
voided during all that time, at least with the knowledge of the nurse, who 
was a most accurate and competent person. It would seem to be much 
more dangerous in the Parisian hospitals than in private practice in this 
countn.', since MM. Guersant and Blache speak of having seen it prove 
fatal in twelve, fourteen, and thirty-six hours, after one or two weeks, or 
even two or three months : and MM. KlllJL't and Barthez refer to it as often 
proving fatal. 

Diarrhfra is not an unf-onimon arcidcnt in the disease. It generally 
depends on simple functional derangement of the bowels. In some cases, 
however, it is so severe or long-continued as to constitute a serious compli- 
cation. Under these circumstances, it depends on follicular entero-colitis, 
or slight er}'thematou8 inflammation of the intestinal mucous membrane. 

In some cases, chronic angina remains after the subsidence of the dis- 
ease; so, too, cor}'za may persist, even taking the form of oza?na. 

Otorrhflea is a not infrequent sequel, and when following angina, and 
due to the extension of inflammation up the Eustachian tube, may be 
associated with permanent deafness, necrosis of the temporal bone, facial 
palsy, and even abscess of the brain. 

Occasionally during the des^juamative period, a painful swelling of the 
joints appears, attended with a renewal of the fever and, frequently, with 
sweating. This form of rheumatism is in all probability connected with 
the imperfect excretion of some excrementitious substance, owing to the 



736 SCARLET FEVER. 

state of the various emunctories. In rather rare cases, the inflammation 
of the joint runs on to fatal suppuration. 

Bronchitis and pneumonia are rare. Inflammation of the serous mem- 
branes is more common, occasioning in some cases the dropsical effusions 
which have already been treated of. It is in most cases connected either 
with renal disease or with the form of rheumatism above described. The 
pleura is more frequently affected than any other of the serous membranes; 
and not rarely the effusion becomes purulent. 

Inflammation of the investing or lining membrane of the heart also oc- 
casionally occurs. Thus, of 39 cases of endo- or pericarditis mentioned by 
Dr. West, 6 could be traced to an attack of scarlatina. 

Peritonitis is much more rare, and the effusion here also is especially 
apt to be purulent. 

Scarlatina may be coincident with variola or measles. We have never 
seen it in connection with the former, but in two cases which came under 
our observation it was complicated with measles. 

Diphtheria has also been observed not very rarely, usually appearing 
during convalescence. In a considerable number of cases, scarlatina has 
been noticed in the course of typhoid fever. 

In some rare cases, as in the one detailed under the head of prognosis, 
more or less complete paralysis ensues during the convalescence from 
scarlatina. 

Tuberculosis is not nearly so apt to be developed after scarlatina as 
after either rubeola or typhoid fever. 

Anatomical Lesions. — The eruption sometimes disappears entirely 
after death, and on other occasions assumes a deep livid or purple ap- 
pearance. The epidermis is generally loosened upon the integument, so as 
to be peeled off with great facility. The most important lesions, and those 
which seem to belong to the nature of the disease independent of complica- 
tions, are the altered condition of the blood, and congestions of different 
parts of the body, particularly the brain, serous membranes, kidneys, 
spleen, glands of Peyer, and intestinal follicles. We have already alluded 
to the fact that, even when the cerebral symptoms have been most severe, 
and we might expect to find evidences of violent inflammation of the brain, 
nothing is observed after death, in the majority of cases, but congestion of 
the large veins and sinuses of the brain, of the pia mater, or of the cerebral 
substance. There is rarely any unnatural amount of serous effusion into 
the ventricles, or meshes of the pia mater ; and it is evident that the symp- 
toms have been due entirely to the vitiated condition of the blood. Never- 
theless, effusions within the cranium may exist, in some few cases, as has 
been already stated in the remarks upon hydrocephalus. 

The respiratory organs are usually healthy, with the exception of con- 
gestion and serous engorgement. 

According to the researches of Fenwick, Fox, and Murchison, it ap- 
pears that the entire gastro-intestinal mucous membrane is affected in 
many cases of this disease. There is congestion of the subepithelial layers, 
with excessive formation and subsequent desquamation of the epithelium. 
The gastric tubules are greatly distended and obstructed by cells mixed 



SKQUEL.E — ANATOMICAL LESIONS. 737 

with granular and fattv matters, and casts of their calibres are frequently 
found in the matters? vomited or in the contents of the stomach after death. 

The condition of the skin resembles this closely, the rete mucosum being 
thickened, with a formation of numerous round nucleated cells, and the 
sudoriferous glands being often obstructed by the rapidly formed cells. 

The glands of Brunner and Peyer are not untrequently enlarged, and 
they are sometimes reddened or softened. In a smaller number of cases 
the mesenteric glands are slij^htly intlamed and increased in size, and the 
spleen is redder than usual or softened. These lesions have no necessary 
relation to the form of the disease, since they are often absent in typhoid 
cases, and present in those of a ditierent type. 

The kidneys are healthy, with the exception of some degree of conges- 
tion, unless the case has been complicated with dropsy. Under these cir- 
cumstances they usually present the characteristic lesions of tubal nephritis, 
which we have already described. 

The heart occasionally presents the results of inflammation of its lining 
or investing membrane; and in some cases its cavities contain firm white 
ante-mortem clots. 

The blood exhibits very different appearances in different cases. It is 
viscid or serous, dark-colored or light, and fluid or coagulated, the clots 
being of variable color and density. The proportion of its constituent 
elements is change^l. The fibrin maintains its usual relation to the mass 
of the fluid (3 parts in 1000), or it is very slightly augmented, while the 
quantity of the globules is increased to 136 or 146 parts, according to M. 
Andral, instead of 127, in 1000 parts. This increase in the proportion of 
fibrin may be in part the cause of the fibrinous depositions which occasion- 
ally are found in the cavities of the heart, and appear to have been instru- 
mental in causing death. 

In an article on "The Pathology of Scarlatina, and the Relation between 
Enteric and Scarlet Fevers" (Med. Chirurg. Trans.^ vol. Iv, p. 103), Dr. 
John Harley, of London, reports thirty-six cases of scarlet fever, to show 
that the anatomi(*al lesions of that <lisease are the j«ame as those of typhoid 
fever in its early period, and that not unfrequently scarlatina, when long 
r«mtiuued, |)asses into enteric fever. After describing these lesions, he 
-ays (p. 1*2^): " From this view our general conclusion as to the connection 
■■■rl,t fever and enteric Jeter is ineviiable, viz., that the pathological 
< .', / y - accompanying an attack of scarlatina, include all those of the first 
eiage of enteric fever, and are so far identical with them. And it follows, 
Th'-f. f re, that the transition from the former disease to the latter is 
!. ,, J more than a natural {)athological sequence, readily determined by 
any r-au?*e which may increase the intestinal irritation." The italics are 
Dr. Harley's. 

We have, on a few rare occasions, known cases of scarlet fever in our 
! •. where the disease has been prolonged beyond its usual 

i 1 - ;iie some of the phenomena of typhoid fever, but this occur- 

rence has been so infre<juent that we doubt whether it ought to be re- 
-1^? '? ri- fho natural evolution of a pathological law connecting the two 
..: That typhoid fever may attack a child just recovering from 

47 



738 SCARLET FEVER. 

scarlet fever, is as probable as that measles and scarlet fever may directly 
follow each other, or even coexist at the same moment. Of both of these 
accidental coincidences, we have seen a few well-marked examples. Sev- 
eral of the cases described by Dr. Harley, in which typhoid fever certainly 
followed scarlet fever, occurred in patients admitted to hospitals. Five 
occurred in the London Fever Hospital, and in some of these the attacks 
of enteric fever began after full convalescence from scarlet fever ; in one 
on the 28th day of convalescence ; in a second on the 31st day ; in another 
on the 37th day ; in another on the 32d day ; and again on the 56th and 
32d days. We would ask whether in such cases the sequent typhoid fever 
ought not to be explained as the result of fever poison imbibed during the 
residence in the wards of a fever hospital ? 

One very interesting fact observed by Dr. Harley, is the frequency with 
which he found fibrinous clots in the heart and great vessels " during a 
pyrexial state, at any period of the disease. This," he states, "is the 
commonest cause of death during the early stage of scarlatina ; it is in- 
dicated during life by the reduction, often sudden, of a full pulse of about 
120, to a dribble of 150 or 160 almost imperceptible impulses. The failure 
of the heart's action is commonly attended with orthopnoea and delirium 
from obstruction to the pulmonary and cerebral circulations. On open- 
ing the body before it has lost a degree of temperature, and while the hot 
blood is still fluid, the right heart will be found distended, partly with 
dark fluid blood, which coagulates on exposure ; and partly, sometimes 
chiefly, by a large, firm, white, bifid clot continuous through the auriculo- 
ventricular opening. Each portion is interlaced with and firmly adherent 
to the tendinous cords and outstanding muscular bauds of the cavity in 
which it lies, and sends outwards a rope-like continuation, the one into the 
pulmonary artery, and the other into the superior cava. These processes 
not only occupy a large portion of the area of these tubes, but extend 
with their branches upwards into the cranial cavity, and outwards into 
the lungs, whence they may often be withdrawn in ramifications up to the 
eighth degree, and eight or nine inches long. 

*' The left heart was generally empty and firmly contracted ; in one case 
(1) each cavity was occupied by a large fibrinous clot, that in the ven- 
tricle spreading into the brachio-cephalic vessels of the arch of the aorta, 
and that in the auricle sending large ramifying branches into the pul- 
monary veins. In another case (12) the auricle was distended with dark 
softly-clotted blood." 

We desire to call attention to these facts, since we doubt not that they 
explain many of the cases of early death in this disease, in which all 
medical treatment has proved so futile, and also on account of the great 
interest of these observations in connection with the similar results which 
have already been noted in diphtheria. 

Diagnosis. — It is impossible to distinguish scarlatina from the other 
eruptive fevers by the symptoms which precede the eruption. The only 
signs upon which a diagnosis at that time might be grounded, are great 
frequency of pulse, which is characteristic of this disease, some soreness 
or redness of the fauces, and the prevalence of the disease in the com- 



DIAGNOSIS. <oy 

munity. But these are all exceedingly fallacious, and the physician should 
be content to wait for the eruption before he ventures to speak with cer- 
tainty. After the eruption has come out. it can scarcely be mistaken for 
anything else, except it be roseola. 

From measles it may be distinguished by the diti'erences in the pro- 
. Ironies, course, and eruption of the two affections. The prodromic stage 
of scarlatina rarely lasts more than twenty-four hours, and is very often 
much less; that of measles, on the contrary, is almost always from three 
to four days ; in scarlatina the rash appears suddenly, and often spreads 
over the whole body in a single day ; in measles it appears on the face 
first, and extends gradually to the rest of the surface, seldom reaching 
the hands and feet before the end of the second day ; the eruption of 
measles occurs first in distinct papules, which coalesce and form patches 
of an irregular crescentic shape, while that of scarlatina is in the form of 
innumerable minute dots or punctations, placed so closely together as to 
give to large portions of the surface a uniform color, like that produced by 
blushing. The color of the two eruptions is different, that of measles being 
dark like raspberry-juice, and that of scarlatina of a more or less bright 
scarlet tint. The presence of catarrhal symptoms in measles, and their 
absence in scarlet fever ; the absence of angina in the former disease, or 
its very slight character, and the severity of the throat affection in scar- 
latina ; and lastly, the greater severity of the febrile symptoms, particu- 
larly the fre«}uency of the pulse and the heat of skin in scarlatina, are other 
points of ditference which will assist in making the diagnosis, rarely, it 
seems to us, difficult, still more certain.* A very great frequency of the 
pulse is one of the most unfailing symptoms of the early stage of scarlet 
fever. It almost always runs up to 140, 150, or 1(>0, in young children, within 
the first twelve or twenty-four hours, and to 120, 130, 140, or higher, in 
those who are older. Nevertheless, this, like all other symptoms, is some- 
times wanting. We have lately seen a boy, between five and six years 
old, with a marked but very safe attack of the disease, whose pulse ranged 
between 80 and 90 throughout the sickness. This was, however, the only 
case we have ever met with, in which the pulse remained so little dis- 
turbed. 

It is sometimes ver}' difficult to determine with precision between roseola 
and sf-arlet fever. By the eruption alone, we believe it to be often im- 
possible. We have seen quite a number of cases in which the eruption of 
roseola resembled so closely that of scarlet fever, that we should have 
been obligerl to confess our inability to make the distinction had it not 
been for the other symptoms, and particularly the frequency of the circu- 
lation, the heat of the skin, and the throat symptoms. The most impor- 
tant difTerential symptoms are the tint of the eruption, which in roseola 
is mse-colored, in scarlet fever bright-red or scarlet ; the characters of the 
patches of eruption, which are more regular in shape, but of much smaller 
-ize in roseola than in scarlet fever; the absence or very slight degree of 
anginose inflammation in roseola; and, what is decidedly the most impor- 
tant of all, the very much slighter degree of febrile reaction in roseola, 
in which the pulse, instead of being doubled in frequency as it is in scarlet 



740 SCARLET FEVER. 

fever, is scarcely above its natural rate, and in which the heat of skin is 
but little above the standard of health. Moreover, roseola is generally of 
shorter duration, and is a milder affection, and therefore accompanied by 
far less fever and general disturbance of the constitution. 

Diphtheria occasionally resembles scarlatina to so great an extent, as 
to have even led some observers to consider them identical. Thus, there 
is in diphtheria a pseudo-membranous angina, with swelling of the cervi- 
cal glands, and at times albuminuria, and even an erythematous rash. 
We have elsewhere (see article on diphtheria) given at length the differ- 
ential diagnosis between these affections, and will here merely call atten- 
tion to the fact that the rash is a rare exception in diphtheria, and is a 
mere uniform erythematous redness ; that even when albuminuria is pres- 
ent, the urine does not present the other characters noted in scarlatina ; 
and that the condition of the fauces in the two diseases is somewhat dif- 
ferent. There is, further, a wide difference in the sequelae of the disease ; 
and, finally, they do not exercise any protective power whatever against 
each other. 

There is a form of disease known as rubeola notha, epidemic roseola, 
rosalia (Richardson), rotheln, in which there are some of the symptoms 
of both measles and scarlatina ; the eruption appearing on the second or 
third day, at first resembling that of measles, but becoming soon more 
like that of scarlatina. Coryza and angina may both be present, and 
there is subsequent desquamation. Some authorities regard this as a 
union of the poisons of measles and scarlatina, while others consider it a 
separate disease, because epidemics of it occur when neither measles nor 
scarlatina are prevailing. Previous attacks of these latter do not protect 
against it. In an extensive epidemic in the lower part of this city, which 
appeared to be of this nature, not a single case, of the numbers which 
came under our observation, was followed by any of the sequelae of either 
measles or scarlatina. 

Prognosis. — It is impossible to obtain a useful average mortality of 
scarlet fever, since the disease varies so greatly in different epidemics, and 
under different hygienic conditions, that the results obtained during one 
period are inapplicable to cases observed at another. This is proved by 
the experience of almost every physician, and by the evidence of many 
writers. It is proved, also, by the following facts : M. Gueretin {loc. cit., 
p. 283) states that the mortality in the epidemic observed by him was 
about 1 in 12 ; of 99 cases, 8 died. MM. Pilliet and Barthez lost a little 
more than half their cases ; of 87, the total, 46 were fatal. These cases, 
let it be remarked, however, occurred in the Hospital for Children in 
Paris, which will account for the heavy fatality. The degree, however, 
to which the mortality may vary in the same place and under the same 
plan of treatment, is shown by the fact, mentioned by Hillier, that in the 
course of eleven years the annual mortality from scarlet fever in the Lon- 
don Fever Hospital, varied from 2.5 per cent, to 16.5 per cent.; and in 
the Hospital for Sick Children in London, from 9 to 31 per cent. Of the 
274 cases that we have observed, 31, or rather more than one-ninth, were 
fatal. Of the 274 cases, 104 occurred between 1849 and 1853, and in 



PROGNOSIS. 741 

those the mortality was much smaller than in those which occurred prior 
to that year. Of 104, 11 were fatal, or about one in nine and a half 
Seventy-eight cases occurred between 1853 and the spring of 1857. Of 
these 78, only 4, or 1 in 12, were fatal. Of 81 cases observed previous 
to 1849, 13, or about 1 in 6, proved fatal. Of 11 cases occurring in 1872-3, 
3 proved fatal. The mortality met with by ourselves in private practice 
has greatly varied, therefore, in different series of years. In one series it 
was 1 in 6, in another 1 in 9], and in a third 1 in 12. Lastly, to show the 
influence of the epidemic type upon the mortality still more clearly, we 
may state that of the last series of cases observed, 78 in number, 43 oc- 
curred during the epidemic which lasted from the summer of 1856 to the 
spring of 1857, and of these only 3, or 1 in 14, died. 

The prognosis must be based, therefore, in part on the character of the 
epidemic prevailing at the time. It must depend, also, on the nature of 
the case. Mild and regular cases are rarely fatal. Of 206 mild cases 
that have been under our care, only three proved fatal. One of these 
would probably not have so terminated had it not been for the imprudence 
of the nurse. This was, in fact, the case of a young child who had recov- 
ered from the eruptive stage of the disease, but whom the nurse carried 
out of the room in the second week, notwithstanding express directions 
given her to the contrary. The child took cold and was seized with catarrh 
and slight anasarca; on the fifteenth day urajmic symptoms set in, and he 
died on the seventeenth day, comatose, and with convulsive movements of 
different parts of ihe body. The second case was that of the boy thirteen 
years old, already lescribed, who died with sudden hydrocephaloid symp- 
toms, at the end of the second week. The third fatal case occurred in a girl 
between eight and nine years old, who died suddenly at the end of six weeks. 
The patient had convalesced sufficiently to have been out several times, 
but remained very hydrjemic and weak. After being much fatigued one 
afternoon by playing with some little friends, she was seized next day with 
vomiting, and soon after with great difficulty of breathing and extremely 
rapid and feeble action of the heart. These symptoms increased on the 
following day. The dyspntea was most severe, and was attended with 
cyanotic color of the hands and face, and with cold colliquative sweats. 
The lungs were free, there wa.s no cough, and auscultation revealed no 
pericardial lesion. Death occurred suddenly at the end of a day and a 
half No post-mortem was made, owing to cirrumstanres that could not 
be controlknl. Our own opinion was, and is, that tho doath was caused by 
a coagulum in the heart. 

Oravp ca«e8 of scarlet fever are always, on the runitary, exceedingly 
danirf'f'tus : thus of 61 caees of this kind that we have had under charge, 
28, or nearly a half, were fatal. In ordcT to render the description of 
the symptoms of this d&Ni of cases more clear, we divided them into two 
groups ; one, in which the onset of the disease is instantaneous and most 
violent, being characterized by excessive disturbance of the nervous sys- 
tem, taking the form usually of convulsions, but sometimes only of pro- 
found coma ; and a second, in which the symptoms of the onset, though 
severe enough usually from the first to mark the character of the case as 



742 SCARLET FEVER. 

grave, are less violent than in the first group, and especially not marked 
by the occurrence of convulsive phenomena. Of 18 cases belonging to the 
first group, 13 died ; while of 43 belonging to the second, 15 died. Violent 
nervous symptoms occurring early in scarlet fever augur, therefore, great 
danger to the patient, since of 18 cases in which they were present, 13 died, 
■whilst of 43 in which they were more moderate, though still marked and 
severe, only 15 died. 

The character of the nervous symptoms is, therefore, all-important in 
the determination of the prognosis, as the probable termination of the case 
is to be foretold more certainly by a just appreciation of these particular 
phenomena of the disease, than by any other means. Excessive jactitation 
or irritability, delirium, coma, and the hydrocephalic cries, are all unfavor- 
able symptoms, but not in the same degree as are those connected with the 
locomotor apparatus. MM. Killiet and Barthez state that they have seen 
recoveries take place in cases in which the intelligence of the patient had 
been very much disordered, while of those who " during the first fifteen 
days of scarlatina, were taken with convulsions, convulsive movements, 
contractions, in a word, any symptoms affecting the locomotor apparatus, 
all, without exception, died." This does not accord exactly with our own 
experience, though nearly enough so to show how exceedingly dangerous 
are the symptoms just enumerated when they occur early in the disease. 
General convulsions occurred on the first day of the disease in 9 of the 61 
grave cases observed by ourselves, and of these not one terminated fortu- 
nately ; in four they occurred on the second day, and of these three recov- 
ered and one died ; in one they occurred on the ninth day, and this patient 
also recovered ; in another case there were no general convulsions, but on 
the first day there were automatic motions, with involuntary extensor mo- 
tions of the arms and fingers, and on the second day strabismus, with a 
continuation of the automatic motions. This case proved fatal. Of the 
15 cases, therefore, in which marked disturbances of the muscular system 
occurred, only 4 ended favorably. Of 10 subjects in which the convulsive 
phenomena occurred on the first day of the disease not one escaped. Of 
5 subjects in whom these symptoms appeared on or after the second day, 
4 escaped. One of the favorable cases occurred in a boy seven years old, 
who had a general convulsion, lasting several minutes, pn the second day 
of the attack ; this was followed by delirium and coma alternately, but no 
return of the convulsions. The case was a most violent one, and lasted six 
weeks, leaving the child at the termination very deaf, but otherwise in good 
health. The second case occurred in a child five months old. The convul- 
sive symptoms appeared on the ninth day, and consisted of strabismus, 
spasmodic retraction of the head, and occasional slight spasms of the limbs. 
They alternated with coma, and disappeared on the tenth day, until the 
seventeenth and eighteenth, when the strabismus reappeared. The child 
recovered perfectly. The third was that of a very healthy and vigorous 
boy between eight and nine years old, who, on the second day of an attack 
which had begun like a severe cholera morbus, had, twice, fits of insensi- 
bility, with stiffening pf the extensor muscles of the fingers, rigid contrac- 
tions of the flexors of the arms, and spasms of the eyeballs. This case 



PROGNOSIS. 743 

proved afterwards very violent, so that the patient nearly died on the fifth 
day, with asphyctic symptoms caused by very great swelling of the tonsils 
and fauces, and enormous enlariremeut of the external cervical lymphatic 
glands, complicated moreover with extensive acute oedema about the chin 
and front of the neck. These symptoms were followed again by diph- 
theritic deposit covering the whole of the pharynx. He finally, however, 
recovered, perfectly. The fourth case was that of a boy between five and 
six years old, who, on the second day, had an attack of general convul- 
sions, which were repeated frequently on the third day. This patient con- 
tinued ver>* ill for several days, and when, at last, he began to improve 
somewhat in the middle of the second week, it was found that he had lost 
entirely the power of speech, and all control over nearly the whole of the 
locomotor apparatus of the body. He could neither lift his head nor turn 
it ; the legs were immovable ; the hands were perfectly helpless. The only 
motion that remained was a jerking, apparently almost automatic, move- 
ment of the arms upon the shoulders, and the forearms upon the arms. 
But even these were most irregular, and badly co-ordinated. He was very 
much in the condition of a new-born child. It was very difficult to as- 
certain what the condition of his senses was; but after a short time we 
were able to satisfy ourselves that he saw and heard, and only after many 
weeks was he able to hold a very light object in his fingers, then to move 
his head from side to side, and at a still later period to hold it up. At 
the end of about two months, he could sit in a chair when once placed in 
it, but could not sit on the floor unsupported. At the end of three niduths 
he was learning to walk by being held up by the arms. He had never 
spoken a word. The only approach to anything like articulation was his 
ability to hum a low gentle musical note; his intellectual faculties, as ex- 
hibited by signs, had regained their natural condition at this time. At 
the end of ten months, he could speak intelligibly some three or four 
words. The fifth case was that of a male infant, nine months old, who, 
on the second day, had severe general convulsions, followed by very deep 
drowsiness. The eruption became intense, and, on the third day, the con- 
vulsive symptoms recurre<l from time to time, but with less violence. On 
the fourth day he seemed somewhat better, but on the fifth very severe 
auginose symptoms set in, and he died. 

Again, in 20 of the 61 grave cases, severe and more or less prolonged 
delirium or coma occurred, and of these 14 died. We may conclude, 
therefore, that convulsive symptoms appearing early in scarlet fever indi- 
cate a highly dangerous and, in all probability, a fatal attack; while 
severe, and especially prolonged delirium or coma, are also extremely 
unfavorable symptoms, but somewhat less so than are those of a convul- 
sive character. 

Other unfavorable symptoms are : extremely fre<juent or very violent 
pulse; intense heat or unnatural co<jIness of the skin ; persistently elevated 
temperature after deflorescence ; <leficiency or sudden disapi>ea ranee of the 
eruption ; a livid or purple tint of the eruption ; slow and im[K'rfect capil- 
lar}- circulation, as ascertained by presj»ure; the appearance of petechia, 
ecchymoses, or hemorrhages; violent vomiting and colliquative diarrhcea ; 



744 SCARLET FEVER. 

great violence of the throat affection, whether from tumefaction, great 
abundance of pseudo-membranous exudation, or disposition to ulceration 
and sloughing ; and lastly, severe coryza or otorrhoea. A disposition to a 
typhoid state, indicated by dulness of the intelligence, dusky hue of the 
skin, frequent and feeble pulse, dry, brown tongue, sordes on the teeth, 
meteorism, and disposition to diarrhoea, is always dangerous. 

When, on the contrary, the fever is moderate, the cerebral symptoms 
absent or very slight, and the eruption regular, and of a bright tint ; when - 
there is no disposition to typhoid symptoms; when the throat affection is 
mild, and the disease pursues a regular, uniform course, we have every 
reason to expect a favorable termination in a large majority of the cases. 

In addition to these remarks it may be said that neither age, sex, nor 
social position influence the prognosis. A delicate constitution does not 
seem to predispose to a violent attack of scarlatina, and indeed, many of 
the most malignant cases occur in very robust children ; but, on the other 
hand, it has been noticed that in certain families there exists a strong ten- 
dency for the disease to assume a grave and fatal form. 

Treatment. — Hygienic treatment. — -In all cases of the disease, whether 
of the mild or grave kind, the strictest attention should be paid to the 
hygienic condition of the patient. The room in which the child is placed 
ought to be, if possible, large, and at all events well ventilated. The tem- 
perature in winter should be carefully attended to. We usually direct it 
to be kept at from 68° to 70° F., during the early stages of the disease, 
unless the fever is violent and the child complains of heat, in which case 
it may be allowed to fall to 66°, or even 62°. The clothing ought to be 
moderate, not enough to increase the heat of the skin, nor yet so little as 
to endanger chilliness. During the latter stages of the disease, when the 
fever has subsided, and particularly when the heat of the skin has fallen, 
the temperature of the chamber ought to be kept, as a general rule, at 
from 68° to 70°, and, when the child is pale, weak, and chilly, it may be 
maintained w^ith great propriety at 72°. 

One of the most important points in the treatment of scarlet fever is, 
undoubtedly, the management of the patient during the convalescence, 
and especially during the desquamative period. It is during this period 
that the child is liable, as we have already shown in our account of the 
different complications and sequelae of the disease, to dropsy, which is the 
most frequent, and at the same time the most dangerous accident to which 
the patient is exposed. There can be no doubt, we think, from the opin- 
ions expressed by various writers, and also from our own experience, that 
the most common cause of this accident is exposure to cold. Chilling of 
the body, no matter how produced, is . exceedingly apt, when it occurs 
within three, or, more rarely, four weeks from the invasion of scarlet fever, 
to be followed by a more or less marked attack of some form of dropsy. 
It is true, we are well aware, that dropsical effusions sometimes take place 
in subjects who have been guarded in the most careful possible manner, 
and in whom there has been no evident exposure to cold ; but it is also 
true, that a much larger number of those who have been thus guarded, 
escape, than of those who are not thus taken care of. We have, therefore, 



1 



TREATMENT OP MILD CASES. 745 

no doubt whatever, that it is most wise and prudent to confine the patient 
to well-warmed rooms, or at least to the house, for twenty-one or twenty- 
eight days from the outset of the disease. The fact that the attack has 
been a slight one only makes it the more necessary to carry out this regu- 
lation, as it has been found by experience that dropsy occurs more fre- 
quently after mild than after severe attacks. 'M. Legcndre {Bccherchc,-^ 
Anat.-PathoL, p. 311) is of opinion that the patient ought not to be allowed 
to leave the house until the skin, completely deprived of the old epider- 
mis, shall have regained its suppleue^, its smooth and polished appear- 
ance, and all its functions. When, therefore, after a mild case, the des- 
quamation is completely terminated in three weeks, the patient, he thinks, 
may be allowed to go out. But, on the contrary, this period would be 
too short by one-half, if the eruption had been very intense, as the des- 
quamation is, in such cases, scarcely finished on the hands and feet at that 
time. Our own opinion, as already stated, is, that in the cool seasons of 
the year, the patient ought to be restricted to the house during full four 
weeks. 

Treatment of ^Iild Cases. — Mild cases of this disease, those in which 
the eruption is moderate in degree, the temperature but little above the 
normal point, even though the pulse be very frequent, in which neither 
delirium, stupor, nor unnatural jactitation betray threatening conditions 
of the ners'e-centres, need but the simplest treatment. The child must be 
confined to a comfortable, well-ventilated room, and cooling drinks, as cold 
water, lemonade, or orangeade, should be allowed, and indeed they ought 
to be recommended, and the nurse should be made to understand that she 
is not to wait until a young child calls out for drink, but that she is to 
offer it frequently. Young children, or at least some, seem not to know 
when they are thirsty or hot or cold ; they have not yet learned to express 
their sensations in words, and a wise nurse or physician will act for them. 

In all ca.<e3 in which there is heat of skin and frc<iuent pulse, and these 
conditions attend all but a very small fraction of the whole number, the 
patient ought to be kept in bed whilst the fever last«, and for two days 
aftemards. This point in the treatment of all fevers is a most important 
one, and is too often neglected. Cases so treated are apt to be shorter in 
their duration, milder in their symptoms, and less likely to he followed by 
any of the troublesome sequelie so prone to occur, as inflammations of the 
cervical glands, of the car, or of the kidneys. 

In many mild ca.«es no drug whatever is needed. If the bowels are 
pwitively costive, that is to say, if they are not moved every second or 
third day spontaneously, a simple enema, a dose of syrup of rhubarb, a 
baked apple, or stewed prunes, will suffice. If the temperature is high, 
the pulse active, and the patient restless and suffering, sweet spirits of 
nitre, sitlution of the acetate of ammonia, or two or three grains of the 
citrate of potash, with from a half to one drop of deodorized tincture of 
opium, every two or three hours, according to the age, will usually lesson 
the heat and promote quiet. We wish to repeat, however, our opinion 
that in a great many cases of this type, no drugs whatever are necessary. 
The time is fast coming wh^ii ev^n the vulgar and illiterate will no longer 



746 SCARLET FEVER. 

quarrel with the physician because he gives no drugs, not even in in- 
finitesimal closes, and the time has come when the wise and educated trust 
the intelligent physician, so that he need no longer give placebos merely 
for the sake of seeming to earn his fee. 

The diet in these cases should be, for the first five or six days, in great 
measure liquid. Milk, with or without some farinaceous substance, to suit 
the tastes or habits of the patient, or with bread and butter, beef or chicken 
soup, with rice or bread, are sufficient. After five or six days, when no 
severer symptoms have made their appearance, and the disease is on the 
decline, light meats, eggs, stewed fruits, or potatoes, may be added. 

Baths, tepid or warm, or spongings with tepid or warm water, cloths 
wetted with cold or tepid water, applied to the forehead, may be used, ac- 
cording to the judgment of the physician. They are not necessary agents, 
but in certain cases, when the heat of skin tends upwards, when the patient 
is very restless from nervous irritation, and particularly if the child is in 
the habit of being bathed, they may be used with much advantage and 
comfort. 

The throat, in mild cases, rarely needs any special treatment. If, how- 
ever, the patient complains of pain, if there be some uneasiness in swallow- 
ing, or if decided patches of exudation make their appearance on the tonsils 
or pharynx, it will be well to let the child gargle, if it be old enough, with 
solution of chlorate of potash or alum or with flaxseed tea. An excellent 
gargle is one made of a wineglassful of table claret, two wineglassfuls of 
water, and forty grains of chlorate of potash. If the patient is too young 
to gargle, some chlorate of potash or alum can be mixed with powdered 
sugar, and a small pinch placed upon the tongue every two or three hours. 
One part of the chlorate or alum may be rubbed up with five or six parts 
of the sugar. There is no necessity for the application of strong agents of 
any kind to the throat. Even though patches of exudation of considerable 
size appear upon the fauces, they will disappear spontaneously in all cases 
of the kind w^e are discussing. We object to the forcible application of 
medicinal solutions to the throat in young children, unless they are abso- 
lutely necessary to clear the passages of obstructing viscid and offensive 
secretions. In children of a certain type — those of sensitive nerves and 
strong wills, in whom fear of pain on the one hand and will to resist on the 
other form a combination which prompts the child to resist such an opera- 
tion to the last — even though we might hope some benefit from the appli- 
cation, the irritation and exhaustion caused by the struggle, and the agita- 
tion kept up by its expected renewal, will do more harm, we think, than 
the treatment can compensate for. 

Inunction, as one of the means of treatment in scarlet fever, is now so 
well known that we suppose nearly all physicians use it. For our part, 
we order the ointment for external use just as regularly nowadays as we 
do cold drinks and proper food. 

It was first proposed and strongly urged, we believe, upon the profession, 
by Dr. Schneeman, a German physician. Dr. Schneeman makes use of 
bacon fat. He takes a piece about as large as the hand, still covered 
with its rind, in order to obtain a firm grasp upon it. On the soft side of 



I 



TREATMENT OF MILD CASES. 747 

the piece slits are maiie in various directious in order to allow the oozing 
out of the fat. The patient is to be rubbed with this as soon as we are 
aware of the nature of the case, from head to foot, excepting the iiice and 
scalp, every niorning and evening. The rubbing is to be so performed 
that the skin may be regularly but not too quickly saturated with the fat. 
During the process only the part being rubbed is to be uncovered, or the 
whole can be done under the bed-clothes. {Ranking's AbsL, No. 12, p. 26.) 

For our own part, we used the bacon fat but twice, soon finding how 
disagreeable an application it was, and not believing that the salt it con- 
tained could do any good whatever. We now always em})loy an ointment 
made by rubbing together a drachm of pure glycerin with an ounce of cold 
cream ( untg. aq. rosie). We have seen children smeared from head to foot 
with lard, and, what is worse, with goose-grease, with their clothing satu- 
rated, their pillows and sheets a mass of discolored grease, most offensive 
to the eyes and nostrils. This is quite unnecessary. Our own method is 
to explain to the mother or nurse that she must take a little of the oint- 
ment above recommended in the palm of the hand, and with this rub 
gently the various parts of the surface, first one limb, then another, and 
then the body. The ointment should be rubbed in with gentle pressure, 
and it is well, we think, to knead and squeeze lightly the various portions 
of the body being anointed, as is done in the use of the massage of the 
French, or by the "rubber" of the English. These manipulations assist, 
we think, the capillary circulation, which is often a good deal impeded. 
After applying a moderate amount of the ointment, while the skin is well 
softened and oiled, any excess of the material should be wiped oflT with a 
soft towel or handkerchief In this way the anointing is thoroughly ac- 
complished, and yet the clothing and bed linen are not so soaked and 
saturated with the oleaginous substance as to be disagreeable to the 
patient, nurse, or mother. 

There can be no doubt, at the present time, that the employment of in- 
unction in scarlet fever has proved a most useful addition to our former 
means of treatment. In our hands it has had the efl'cct of allaying, in all 
ca*es, the violent irritation caused by the intense heat and inflammation 
of the skin. In nearly all cju«es, it sensibly diminishes the fre«jucncy of 
the pulse, and in many this effect is very strongly marked. It removes, 
of course, the dryness and harshness of the skin, keeping it, instead, soft 
and moist. It lessens or even removes the burning, irritation, and itching 
caused by the eruption. By these effect,s, to wit, lowering of the pulse, 
and alleviation of the external heat, dryne.^s, itching, and irritation, it 
cannot but, and evidently do<J8 modify and diminish, most happily, the 
injurious effects of the disease upon the constitution at large. So great 
is the comfort it gives to the patient that we have several times had young 
children, still untaught to speak, to make signs and motions, at .-shorter 
or longer intervals, showing their desire to have the application renewed. 
The frequency of the application must def>end upon the case. When the 
eruption is intense, the skin very hot, and the febrile symptoms marked, 
they should be made every two or four hours, or even oftener. In milder 



748 SCARLET FEVER. 

cases they Deed to be repeated only three or four times in the twenty-four 
hours. 

Treatment of Grave Cases. — The most dangerous cases of this dis- 
ease are those of the type described at page 720, in which the attack is 
sudden, and in which disorders of the nervous system in the form of con- 
vulsions, tremors or rigidity, retraction of the head, delirium, stupor, or 
coma appear within a few hours of the onset. When this type of the 
disease attacks very young children, they, so far as we have seen, nearly 
always die in sixteen, twenty-four, or forty-eight hours. Older children 
have more chance of escape, but, even in them, the danger is extreme. 

We have seen everything tried in these cases, from depletion by bleed- 
ing and leeching, many years since, to expectancy, and must confess that 
we have little faith in the power of human agency to contend against this 
particular array of symptoms. Depletion is no longer, we believe, thought 
of by any, and there is often no time for the action of drugs. 

It is in such cases that the' use of water at different temperatures, and 
applied in the form of baths, affusions, packings, ablutions, and ice has 
been recommended, and has seemed in some cases to do good. We shall 
give a rapid sketch of the opinions of those who have used these means, 
and then state our own views. 

Dr. J. Currie, of Edinburgh, was the one who first and most promi- 
nently brought before the profession the use of cold water in this disease. 
It must be observed, however, that Dr. Currie limits its use to cases to 
w^hich he applies the term anginose, many of which, we doubt not from his 
description, ought to be classed as mild cases. He mentions another class 
of cases which he thinks ought rather to be called " purpurata," charac- 
terized by " extreme feebleness and rapidity of the pulse, and great fetor 

of the breath The heat does not rise much above the standard of 

health. Great debility, oppression, headache, pain in the back, vomiting, 
and sometimes purging, accompany its rapid progress ; the patient sinks 
into the low delirium, and expires on the second, third, or fourth day. 
.... The cold affusion is scarcely applicable to it, and the tepid affusion 
makes little impression upon it. In my experience, indeed, all remedies 
have been equally unsuccessful. It outstrips in rapidity, and it equals in 
fatality, the purple confluent small-pox, to which it may be compared." 
{Curriers Med. Reports^ Philada. ed., p. 277.) It is clear, therefore, that 
Dr. Currie, when he speaks of nearly invariable success in upwards of 
one hundred and fifty cases (p. 286), had to do, not with the malignant, 
or, at least, not with the most malignant forms, for which we are seeking 
a remedy, but with cases of a mild form, or at most with those of the 
severe anginose type. Indeed, at page 294, we find the following remarks : 
** It has come to my knowledge, that in two cases of scarlatina, of the 
most malignant nature, the patients have been taken out of bed, under 
the low delirium, with the skin cool and moist, and the pulse scarcely per- 
ceptible. In this state, supported by the attendants, several gallons of 
perfectly cold water were madly poured over them, on the supposed au- 
thority of this work ! I need scarcely add that the effects were almost 
immediately fatal." We have been induced to enter thus much into detail, 



TREATMENT OF GRAVE CASES. 740 

in regard to the use of cold aftusious, because of the iutriusic importance 
of the subject, and because of the remarks upon it in the >York of MM. 
Rilliet and Barthez, who bring forward Currie's success a^ a strong argu- 
ment in favor of their employment of them in that form of the disease in 
which cerebral symptoms predominate. Currie does not recommend them, 
however, except in case^ in which the reaction is full and strong, as indi- 
cated by very great heat of skin, scarlet eruption, and rapid, but not feeble 
pulse. In the famous cases of his own two children, it is evident that the 
attacks were not malignant, for the skin was very hot (108° and 109° F.), 
and no mention is made either of stupor or delirium, much less of convul- 
sive phenomena. Dr. George Gregory, of London, whose opinions upon 
ail matters connected with the eruptive fevers are of course worthy of 
great weight, says {Led. on the Eruptive Fevers, edited by Dr. Bulkley, 
New York, p. 190), in relation to the use of cold affusions: "Sanctioned 
by my uncle, the late Dr. Gregory, of Edinburgh, this plan has been 
amply tried in all parts of the world, but it has not realized the expecta- 
tions of its proposer. 

" The truih is that the cold affusion is applicable only to a small num- 
ber of cases. It is adapted for young people with high anginose inflam- 
mation and a burning hot skin, without plethora, without depression of 
nervous energy ; but it is inapplicable to the scarlatina of adults, accom- 
panied with coma, phrenitis, or marked debility. It is wholly unfit for 
causes of cynanche maligna. It answers its purpose very well for the first 
day or two, but it is often impossible to continue its use. Lastly, it seems 
to increase the disposition to dropsy." 

Dr. Currie's method of using water was by effusion. The child is un- 
dressed and placed erect or sitting in a tub, while four or five gallons of 
water, at from 60° to 70° F., are poured over the head and body. The 
good effects of the remedy are said to be an immediate reduction of the 
heat, a diminution in the rapidity of the pulse, which, in one of Dr. Greg- 
ory's children, fell in half an hour after the cold affusion from 160 to 120, 
a disposition to sleep and quiet, and, according to Dr. Gregory, a seeming 
arrest of the throat affection. These good effects of the affusions are tran- 
sient, however, as the heat of skin and rapidity of the circulation return 
in the course of one or two hours. For this reason it is necessary to re|>eat 
thera frequently, once in two or three hours at least, in order to render the 
effects permanent. Currie used fourteen affusions for one of his own chil- 
dren, and twelve for another, in thirty-two hours. These were not, how- 
ever, all cold. Gregory u.«*ed for his child five "good sousings," to use his 
own words, in twenty-four htjurs. 

MM. Rilliet and Barthez give, in the following words, the conclusions 
of Henke in regard to the use of cold affusions: 1. Cold affusions are not 
adapted for a general meth(xl of treatment. 2. The slight, or simply in- 
flammatory forms, do not all demand so energetic a treatment. 3. Their 
employment must be reserved for ca."ie8 in which the disease is epidemic, 
and accompanied by intense heat and dryness of the skin, with smallness 
and acceleration of the pulse, anfl for those in which the cerebral symp- 
toms are very violent and characterized by great restlessness, alternating 



750 SCARLET FEVER. 



with drowsiness, commencing from an early period of the disease, Scarlet 
fever under these circumstances is so dangerous, they say, and so often 
mortal, that recourse ought to be had to all curative means, and in chil- 
dren the cold affusions are much more strongly indicated than bleeding 
(op. cit, vol. ii, p. 653). 

Dr. Hiram Corson, of Montgomery County, in this State, has, so far as 
we know, used cold externally more boldly than any one in this country. 
He began this treatment in 1844, and, in a report made by him to the 
Pennsylvania State Medical Society, " On the External Application of Ice 
to the Throat as a Remedy in Scarlet Fever and Diphtheria" (see Transact, 
of the Med. Soc. of the State of Pennsylvania, for the year 1864), declares his 
unabated faith in the excellence and safety of the treatment. He advises, 
in cases attended with convulsions, the pouring of cold water from a height 
of a few feet on the head for several minutes at a time, — this to be re- 
peated every fifteen or twenty minutes until relief is obtained. At page 
467, he says : " Hundreds of times have I had patients brought to the 
side of the bed and cold water poured freely over the head, until the stu- 
pid, almost comatose child, was yelling, and kicking, and striking to get 
rid of the falling water ; and this I have repeated whenever the symptoms 
called for its repetition." He prefers in these cases the cold afifusion to 
ice. He also applied pieces of ice wrapped in cloths, to the neck, when 
the anginose symptoms were severe, and, when the temperature was very 
high, washed the whole body with iced water, until the heat was reduced. 

Dr. Corson, in this article, speaks with the greatest possible confidence 
of his treatment, and when others evince some dubitation as to the invari- 
able success of the cold treatment, avers that they had used it imperfectly 
or with timidity. It is really unfortunate that his paper deals altogether 
in general assertions. At page 458, he says : " And now, after twenty 
years of experience in the use of it, and after treating scores and scores 
of cases, I am most happy to say that I have never seen the least injury 
produced by it, but, on the contrary, regard it as the means, above all 
others, of comfort and safety to the patient." He does not refer to a single 
fatal case during the twenty years he has been using this system. At page 
453, however, he speaks of having " during the whole winter, in about one 
hundred cases, continued the treatment in degrees apportioned to their 
mildness or severity, and without the loss of a single patient thus treated." 

Nevertheless his experience is valuable, for it shows that, in some cases, 
at least, the use of means which reduce rapidly the heightened tempera- 
ture of the body in scarlet fever, acts as favorably as it has been found to 
do in the hyperpyrexia of sunstroke, rheumatic fever, and in continued 
fevers. 

Hillier (Dis. of Children, p. 326) states that he has employed cold affu- 
sions with good effects in a few malignant cases. He used water from 70° 
to 75° F., wrapping the child immediately after the aflTusion in dry blankets. 
He adds that " in cases of collapse with cold extremities, it would not be 
prudent to resort to the operation." 

Trousseau {Clin. Med., Syd. Soc. ed., vol. ii), recommends cool or cold 
affusions when dangerous ataxic nervous symptoms make their appearance. 



^1 

let ^ 



I 



TREATMENT OF GRAVE CASES. 751 

At page 198, he says : " I declare to you that I liave never resorted to the 
eraploynieiu of eoUl aftusions without obtaining beneficial results. I am ftir 
from pretending that all my patients recovered : like my colleagues, I have 
lost the greater number, but even those who died experienced a temporary 
relief frotn suftering, and the affusion, so far from proving injurious to them, 
always moderated the symptoms, and also seemed always to retard the 
fatal termination." At page 20(), he states that he does not use them in- 
discriminately in all cases, but only ** to subdue serious nervous complica- 
tions — formidable ataxic symptoms." 

Dr. Gee (Reynolds's Si/4. of Med, vol. i) speaks of the cold affusion as 
being sometimes useful in the malignant form of the disease, attended 
with delirium, diarrhcea, vomiting, full pulse, and great heat of skin. He 
adds, however (p. 355), that in the " primary adynamic form, all treat- 
ment will be baffled. The cold affusiou is the only means which has 
seemed to me to be of even momentary benefit." 

We shall now refer to our own experience in the employment of exter- 
nal cold. We never use it to its full extent except in really dangerous 
cases. So long as the case is mild or moderate, or even severe, if there 
be no cerebral, and especially no locomotor disturbances, we deem it un- 
necessary, and rest content with more simple means ; or we use simply ab- 
lutions with tepid or cool water, with cold applications to the head, so long 
as they are agreeable, and until the temperature is reduced. But, when 
the temperature rises very high (105°), or, as Currie states in one case 
112^, and Dr. Woodman (Wunderlich on Medical Thermometry, ^yd. Soc. 
ed., p. 204, footnote), 115° F., with nervous symptoms, the danger is ex- 
treme, and we have used, and shall use heareafter, means to reduce the 
heat. In one case we made repeated affusions upon the head with water at 
70°, pouring at one time seven bucketfuls upon the part. This was a case 
attended with coraa, strabismus, and spasmodic retraction of the head. In 
addition to the affusions, cloths dipped into iced water, were kept applied 
the greater part of the time. These means, especially the affusions, were 
evidently advantageous, and the child recovered. 

We have made use of lotions with cool water (70° to 72°) in three grave 
cases. In two they were evidently useful ; in one they did no good, and 
were perhaps injurious, as we believe now that the case might have been 
better treated with prolonged warm baths at a temperature of 92° to 95°, 
cold to the head, and internal stimulation. The latter case was one in 
which the patient had two convulsions on the first day, and one on the 
second. The pulse rose at once to between 160 and 170; the head and 
trunk were very hot, whilst the extremities were coolish ; the child was 
either excessively dull or comatose. Cloths wet with iced water were kept 
constantly upon the head and the body, and occasionally the limbs were 
sponged with cold water. The internal remedies consisted of carbonate of 
ammonia and milk punch. The patient improved decidedly on the third 
day, so that the pulse came down to 152, the intelligence returned, though 
the child was still very drowsy and heavy, and the case looked quite prom- 
ising. On the fourth and fifth days, the throat afffction came on ; the neck 
and throat swelletl enormously, the cervical lymphatic glands became very 



752 SCARLET FEVER. 

large, the nasal passages discharged streams of offensive grumous pus, the 
ears ran copiously, the fauces became pseudo-membranous, the deglutition 
grew worse and worse, until at last it was impossible, and the child died 
on the middle of the sixth day, a mass of the most disgusting and offen- 
sive disease. One of the grave cases in which the cool applications proved 
useful, occurred in a hearty, vigorous girl, twelve years of age. On the 
third day of the attack, the symptoms were as follows : the pulse was be- 
tween 160 and 170, small and quick; skin intensely hot ; eruption very 
copious and of a dark red color tending to violet ; capillary circulation 
slow and languid ; tongue black, and covered with a hard, dry crust ; 
teeth and lips dry, and covered with dark incrustations. There was very 
great agitation and restlessness, with constant moaning and complaining, 
and total insomnia. Under these circumstances, we directed the nurse to 
sponge the head and extremities of the patient with water of the tempera- 
ture of the room (68° to 70°). As the water became heated by contact 
with the skin, small pieces of ice w^ere put into the basin so as to keep the 
temperature at the point mentioned. At the end of four hours, the wash- 
ing having been continued all the time, we found the patient decidedly 
more comfortable. The pulse had fallen to 140, and increased in volume; 
the heat of skin was much reduced ; the color of the eruption had im- 
proved, having become much more scarlet in tint ; the capillary circula- 
tion was more active; the agitation and restlessness had very much mod- 
erated, and the child had slept somewhat at short intervals. This treat- 
ment, in conjunction with the internal administration of the solution of 
chlorinated soda, and small doses of spirit of turpentine, was continued for 
several days, the sponging being used whenever the heat and restlessness 
were great, and the pulse very rapid. The child convalesced about the 
end of the third week, but was unfortunately seized with uraemic symptoms 
on the twenty-fifth day, and died in twenty-three hours, after the most 
frightful convulsions we ever saw. 

Since the publication of the last edition of this work we have seen but 
little grave scarlet fever, and our experience as to the exact value of cold 
has not been much increased. It was used by our advice in the follow- 
ing case, of the most violent type, to which we were called in consultation. 

Case. — The patient was a girl, two years old, who, seized in the morning of one 
day with vomiting, fever, and restlessness, had, during the following night, hot 
fever, violent jactitation, and moaning. She rofujed all food. Next day, at 9 a.m., 
when we saw her, she was imminently ill. She knew no one, paid no attention to 
father or mother, tossed incessantly about the bed or in their arms, so that it was 
almost impossible to hold her; and at times had rigid contractions of the muscles, 
like those in tetanus. The features were drawn and rigid; the pulse running up- 
wards of 180, very feeble and small ; the skin very hot, but there was no eruption. 
The latter fact might throw some doubt on the diagnosis; but the character of the 
symptoms, the rapid fatality, and the fact that a few days afterwards two children 
were seized with distinct scarlet fever in the house opposite, leaves no doubt in our 
own mind. The prognosis was as bad as it could be, and so we announced, but added 
that external cold ought to be tried. The body temperature was very high, and we 
directed basins of water with ice in it, as used by Dr. Corson, to be prepared. Towels 
wrung out of this water were kept on the head, and the body and limbs sponged 



TREATMENT OF GRAVE CASES. 753 

■wilh tho cftmo until the heat fell, when the washings were suspended tempornrily, 
to be renewed when the hent rose agiiin. The treatment was carried out very cor- 
rectly, as there was a medical man present all the time, but it was of no use what- 
ever. The child died at V2 m. of that day, in a little over twenty-four hours from 
the onset. 

This case was not a fair test of the value of the treatmeut. The cold 
was applied too late to show clearly what may be il^ power. But we con- 
fess that its total fiiilure, though used withiu tweuty-four hours of the 
inception of the disease, is a melancholy proof of the extreme danger of 
such cases. 

A second case, which occurred about the same time, also shows the vio- 
lence of this form of the disease. 

Case. — A very healthy girl, within a few days of two years old, whose sister 
and two of whose cousins had been ill with scarlatina in the same house for some 
ten days, was seized at six in the morning with vomiting. She then slept for a 
time and vomited again. At 9 a.m. she had a convulsion, which lasted, with short 
lulls, during which she was comatose, until 6 p.m., when one of us saw her in con- 
sultation. She was then very hot, covered with a copious, dark, dingj' eruption, 
and insensible. Despairing of any other treatment, we advised cold externally, 
and arranged for its use by a physician, with the thermometer as a guide. Before 
the treatment could be commenced, the child became again convulsed and died. 

After thus stating the conditions under which we think external cold 
may be properly used, we must protest against its indiscriminate use in 
all cases of dangerous scarlet fever. If the reader will glance back at page 
748, he will see what Currie thought of the rash use of his cold affusions, 
and what Dr. Gregory also states of the effects of cold. 

When the body, instead of being hot, is cool — when a dingy and stagnant 
capillary circulation shows a feeble and struggling heart, it would be most 
dangerous to use cold. Here the warm or tepid bath or affusion should 
be used, or warm mustard foot-baths may be resorted to every two or three 
hours. If, even wiiilst the body and limbs are cool, the head is hot, it 
would be proper to apply cold by cloths or affusion to that part, whilst 
the body is immersed in warm water or wrapped in proper coverings. 

The true guide as to the propriety or impropriety of using cold is, none 
can doubt now, to be found in the thermometer. The method followed by 
Drs. Wilson Fox and H. Weber in the ca.ses of hyperpyrexia occurring in 
the course of rheumatic fever is the one which we propose to use ourselves 
and to recommend to others. It is the only scientific one, and therefore 
the one which can be accurately described and followed. If errors occur, 
they can be definitely stated and afterwards avoided. If successful, the ex- 
act means which led to success can be ascertained and communicated in pre- 
ci.«e language. Dr. Fox published his cases first in the London Lancet, and 
then presented them in a separate form as an e.«say, " On the Treatment of 
Hyperpyrexia, as Illustrated in Acute Articular Rheumatism, by Means 
of the External Application of Cold;" Macmillan & Co., London, 1871. 
Dr. H. Weber's case is to be found in the Traiisadious of the Clinical Society 
of London^ vol. v, p. 136, under the title of "A Case of Hy|K'rpyrexia 

48 



754 ■ SCARLET FEVER. 

(Heatstroke) in Rheumatic Fever Successfully Treated by Cool Baths 
and Affusions." 

The first point to be determined is the degree of temperature which be- 
comes dangerous to life, and to prevent or reduce which we may and ought 
to resort to the application of cold externally. Of course there is but one 
certain guide to the temperature of the human body, — the thermometer. 
A practiced hand may be relied on when no thermometer is to be had ; but 
no hand, however experienced, can give the certainty of the thermometer. 
Inasmuch, too, as the state of hyperpyrexia is always attended by con- 
comitant phenomena of a peculiar kind, these, to the experienced phy- 
sician, will assist in guiding him in his treatment. These phenomena con- 
stitute the group called ataxic or adynamic nervous symptoms. The 
patient is usually delirious and restless or comatose, and not unfrequently 
has local or general convulsive movements; the pulse is frequent and 
feeble, and sometimes so small as to be felt with difficulty, and the capil- 
lary circulation is sluggish and congested ; the respiration is usually hurried 
and embarrassed, so that the patient is readily judged to be in extreme 
danger. 

According to Dr. Fox, a temperature in rheumatic fever which rises 
suddenly from 103° or 104° to 107°, 108°, or 109°, has usually proved 
fatal within a very short time after the latter temperature (109°) has been 
reached. He, however, saved one patient, by external cold, in whom it 
reached 110° in the rectum. Dr. H. Weber thinks that until the cold 
treatment was used, a temperature of 108° had been nearly always fatal. 
Dr. Fox asks the question. After what degree of temperature attained by 
the human body in febrile states is recovery naturally possible without 
medical interference ? He states that the highest recorded temperature 
he knows of after which recovery has taken place (with the exception of 
relapsing fever), was in a case of tubercular pneumonia, in which it rose 
suddenly from 105° to 108°, and then suddenly fell to 104°. He refers, 
of course, to cases not treated by cold, since, as stated above, he himself 
saved a case in which the temperature had reached 110° in the rectum. 

It must not be forgotten that the axillary temperature is less than that 
of the mouth, under the tongue, and that this is less than that of the vagina 
or unloaded rectum. Wunderlich gives the averages in the adult as fol- 
lows : For the axilla, 98.6° F. ; for the mouth, 98.78° to 98.96° ; and that 
of the vagina or unloaded rectum, 99.14° to 99.5° F. In children the tem- 
perature is more variable, but does not differ very greatly from that of the 
adult. M. Roger gives 98.97° as the average axillary temperature be- 
tween 4 months and 6 years, and 99.15° between 6 and 14 years. Dr. 
Finlayson, in 21 children under 6 years, found the morning temperature 
in the rectum to be 99.41° F. 

Such being the normal temperatures, we will now give those which have 
been observed in scarlet fever. Wunderlich (Med. Thermometry ^ Syd. Soc. 
ed., p. 348) says that the height reached by the temperature in scarlet fever 
is almost always above 104° F., very commonly over 104.9°, while in cases 
which terminate favorably it seldom exceeds 105.8° F. The translator of 
Wunderlich (Dr. Woodman, footnote, p. 221) gives the noon temperature 



TREATMENT OF GRAVE CASES. 755 

of typical nou-malignant scarlatina in a good many cases as 105°, 104°, 
103°, and 102", on the first, second, third, and fourth days. In a note at 
page 204, he states that he has put on record {Med. Mirror for February, 
1865) some fatal cases of scarlet fever in which the temperature reached 
115^. ** The observations were made with one of Negretti and Tambra's 
thermometers, divided into fifths, which had been recently compared with 
a standard." 

From these fact^ we may assume that a temperature of 105° F. in 
scarlet fever is not necessarily very dangerous to life, but that from the 
moment it tends to rise above this point, the patient enters into a very 
dangerous period. 

If, with a temperature of 105°, there appear any of the nervous phe- 
nomena so often alluded to, delirium, drowsiness, coma, vomiting or purg- 
ing, and especially any locomotor disturbances, the time has come for the 
use of external cold ; and should the temperature continue to rise after it 
has reached 105°, the cold treatment ought to be resorted to, even though 
these nervous phenomena have not shown themselves, since they will be 
almost certain to appear should the temperature go on rising. 

And next as to the best mode of applying cold. It does not matter 
much how this is done, if only it be so managed as to reduce with cer- 
tainty the heat of the body towards the normal point. Dr. Fox used 
baths at different temperatures, and in one case applied ice to the chest 
and along the spine in an ice-bag, whilst he reduced the temperature of 
the bath rapidly from 96° to 6G^. At other moments in the same case he 
used the ice-bag applied to the spine for several hours at a time, and on 
-till other occasions employed the cold pack, wrapping his patient in a 
rheet wrung out of ordinary cold water (probably 60°). Dr. H. Weber 
placed his patient (a boy of 16) in a bath at 71° F., keeping him there 
the first time thirty minutes, when the temperature under the tongue had 
lallen from 108.2° to lUl.8°. Some hours afterwards, when the tempera- 
ture had risen to 105.8", the patient was again put into a bath at 72^, and 
water poured over the back of the head and neck. In twenty-five minutes 
the temperature fell to 101. 

Dr. Fox says, at page o4 : "I believe, however, that the bath may be 
altogether dispensed with, and that for the future it will be sufficient to 
place a Mackintosh sheet under the patients, so arranged that the water 
may escape into a receptacle, and to pour cold water over them from time 
to time." 

Dr. Corson uses affusions of cold water over the head of the child, which 
IS held over a tub, as the most powerful means in cases of coma or con- 
vulsions, and, when the temperature is very high, washes the whole body 
with iced water, or even rubs it with ice. 

The most convenient mwle, it appears to us, in children, will be either 
the one proposed by Dr. Fox, the Mackintosh sheet on the bed, and affu- 
sioDS of cold water; or a bath-tub or common large wash-tub, containing 
WAter at a temperature proportionerl to the heat of the body, 80^ to 70 , 
with affusions of cold water upon the head, or the application of towels 
wrung out of cold or iced water to the head >" ^oon as the thermometer, 



756 SCARLET FEVER. 

held in the rectum or under the tongue, shows that the temperature has 
fallen to 101° or 102°, it will be best to remove the patient to bed between 
two blankets. Not unfrequently, a» the temperature falls, the patient be- 
comes partially conscious, grows paler, and shivers, and these are signs 
which show that it is time to cease, at least temporarily, the use of the 
cold. 

The physician, when he first uses this mode of treatment, should know 
that the temperature is apt to continue to fall, even after the use of the 
cold has been suspended. Thus, in one of Dr. Fox's patients it fell from 
103° to 99.4° after the removal from the bath. The danger to be appre- 
hended from these continued falls in the temperature is not so great as 
might be supposed. Thus, Dr. Fox says that it may be doubted whether, 
in future cases, any external warmth may be necessary to prevent too 
great a fall of temperature. " Even severe collapse produced by cold has 
been shown by F. Weber's, Bartel's, and Ziemssen's observations on the 
pneumonia of children to be less dangerous than it at first appears." 
And Dr. H. Weber says, "Although the duration of the bath will be in- 
fluenced in some degree by the temperature of the water, we must be en- 
tirely guided by the condition of the patient while in the bath ; the heat 
of the blood ought to be reduced, if possible, to almost its normal degree, 
and the nerve-centres ought to be reduced to a more healthy condition." 

After the heat has been once reduced by the cold to near its normal 
state, the patient must be carefully watched by means of the thermometer, 
and if the heat rises again, the cold should be reapplied. This may have 
to be done several times a day at first, and less frequently afterwards, if 
the treatment prove successful. It is not always necessary to resort to the 
bath in every rise of the heat. Cold to the head, afi'usions upon the head 
alone, the application of an ice-bag to the spine, or the use of the cold 
bath, may suffice to keep the temperature within the safe limits. 

While the cold is being used to reduce the temperature, we may employ 
certain internal remedies with advantage. If the patient is not very much 
exhausted, we may make use of the antiseptic salts of Polli, to which 
reference will presently be made. But if the exhaustion be very great, if 
the circulation is rapid, feeble, and uncertain, with a dusky and congested 
skin, we should use brandy with milk, beef or chicken tea, and wine-whey. 
Dr. Fox used in the two cases which recovered (adults) very large quan- 
tities of brandy, from twelve to eighteen, and even thirty-three, ounces in 
twenty-four hours. He gave also large amounts of beef tea, two to three 
pints, and as much milk as three and four pints. In such cases quinia 
and carbonate of ammonia would also be proper means until the vitality 
is restored. 

In a former edition of this work it was stated that we had used the 
hyposulphite of soda or magnesia in 11 cases, of which 2 were malignant in 
type, 3 grave, and 6 moderate. All these recovered. It was then said 
that so small an experience was of little weight in determining their value. 
Since that time we have used the same salts in most of the cases that we 
have seen. Only 4 of these could be called grave. They were not of the 
convulsive form, but exhibited high fever, severe anginose symptoms. 



TREATMENT OF GRAVE CASES. 757 

tedious duration, and copious desquamation. They were severe, but not 
malignant cases; and they all did well. In two cases of the malignant 
form, with profound adynamic nervous symptoms from the very onset, 
they were also freely used, but without effect. On the whole, we think 
these salts deserve a further trial. The soda or magnesia salt ought to be 
selected according to the state of the bowels. When these are constipated, 
the magnesia is to be used. In the contrary case, or when the bowels are 
in a relaxed state, we use the soda salt. The dose of either is five or ten 
grains, every two hours, according to the age. They are best given in 
solution in water, with a little ginger syrup. 

There are a class of cases which, though they do not exhibit the ex- 
treme severity of those we have just considered, well deserve the name of 
grave. The temperature is high, the pulse rapid, the nervous system 
shows disturbance by extreme agitation or by drowsiness ; there may be 
muscular starting, or tremors, or a single slight convulsion ; the eruption 
is very abundant, and vivid or dark in tint, and the anginose symptoms 
are marked and severe. Such cases are dangerous ; seldom last less than 
two or three weeks, anti require all the care of the practitioner and nurse. 

In this second grade of the grave form the temperature ought to be 
reduced, using the thermometer as a guide, at the beginning by the care- 
ful use of the cool or tepid bath, or by cool or tepid ablutions, and by the 
use of cold water or ice to the head. Internally, the hyposulphite salts or 
an alkaline febrifuge ought to be administered for the first few days. In 
addition to this, we may employ with advantage full doses of quinia or 
ealicylic acid ; both of which, and especially the latter, possess the prop- 
erty of greatly reducing the degree of febrile heat. 

The patient often, indeed generally, in this class of cases, sinks after a 
few days into a low ataxic condition. Here the best remedies, we think, 
are chlorate of potash with muriated tincture of iron, quinia with niuri- 
ated tincture of iron, or muriated tincture of iron with solution of acetate 
of amraonia and dilute acetic acid. Hillier thinks that in such cases the 
beet medicine is carbonate of ammonia, and Trousseau also advises it 
stroogiy. These medicines may be given in the following modes: 



B.— Pot*fs. Chloral., 


• .^• 


Tr. Ferri Chlorid., 


• f^j- 


Syrup. Zingiber; 


• r^vij. 


Aquae, 


. f5ij.-M. 


Do«e, A tewpoonful every two hours at five years of 


age, and under that age, 


half a teaspoonful. 




E— Quinia? Sulphat., 


. pr. xij. 


Tr. Ferri Chlorid., 


• f^j. 


Syrup. Zingib., 


• f.^v. 


Srrup. Simp., 


• f.^ij- 


Aqu», 


. f5'J-M. 



D<we, a teaspoonfal everj two hours at five years, and under that age, half the 
quantity. 



V58 



SCARLET FEVER. 



R.— Tr. Ferri Chlorid., . 


. . . f^j. 


Acid. Acet. Dil., 


• • . m- 


Liq. Amnion. Acetat., 


. . . f^vj. 


Syrup. Simp., .... 


. f^ss. 


Aquae, 


. . . f^iss. 



-M. 

Dose, a teaspoonful every two hours at five years of age, and under that age, 
half the quantity. 

The dose of carbonate of ammonia is from two to three grains every 
two hours at five years, given in a mixture of syrup and gum, or in milk 
and water. 

In all severe cases attention to the diet is highly important. At first 
only milk and broths should be allowed. After a few days bread or some 
other farinaceous substance may be added. Until the fever has disap- 
peared in great measure, no other diet ought to be permitted. The cases 
are very uncertain in their course. 

Under certain conditions alcohol must be used as has already been said. 
When the tongue is dry, the skin harsh, the pulse rapid and feeble, the 
cardiac impulse weak, the muscular force prostrated, we use brandy or 
whisky, or wine in the form of wine-whey, or mixed with water. The 
choice between these agents must depend on the degree of vital, and espe- 
cially of circulatory, prostration present, and the fancy of the patient. 
We use brandy generally, giving it in milk or water. From ten to twenty 
drops at the age of one or two years ; from twenty to forty drops between 
two and five years of age ; and after these ages from half a teaspoonful 
to a teaspoonful every two or four hours, or three or four times a day, 
according to the efl^ects produced upon the pulse and nervous symptoms, 
are the doses we have found best. When wine-whey is preferred, one or 
two teaspoonfuls every hour or two hours, at two years of age, and a table- 
spoonful at the age of four or five and upwards, may be given. 

Treatment of the Angina. — The angina is seldom troublesome before the 
third day. It never becomes, we think, a source of danger in itself, in the 
cases destined to end fatally on the first, second, or third day. But, when 
the case begins with grave nervous symptoms, and the patient survives 
these, the throat almost always exhibits, on the third or fourth day, the 
conditions which have already been described, and which partake so much 
of the character of severe diphtheria. The general treatment ought to be 
steadily persevered in, — that by the hyposulphites, or by the muriated 
tincture of iron, with or without chlorate of potash and quinia, as has 
been described. The local treatment should consist, in the early stage, of 
cold applications, if the constitutional state of the patient will allow of 
it. When the circulation is active, and the temperature of the body high, 
there need be no fear as to the u.se of cold. When, on the contrary, the 
heat is not high, it should be used with caution, and, if the temperature 
falls rapidly under its use, it must be abandoned, or used only from time 
to time, and with great care. When the temperature continues rather 
low, warm poultices, inclosed in portions of thin, soft flannel, and secured 
by a light cravat round the neck, may be tried. They may prove com- 
forting to the patient. 



CASE. 759 

When the cold is to be used, pieces of ice wrapped in flannel, and ap- 
plied behind the angle of the jaw, or cloths wetted with iced water, may 
be employed. We have used the cold several times, and in two cases 
with marketi beuefiL lu one case, which we shall relate, the efl^ects were 
most striking. 

Cask. — The pationt wa.* a boy botweon eiccht and nine years of a^o, who had had 
slight convulsive niovemenls and delirium on the first day, violent jactitation and 
unconsciousnes< on the second and third days, with very active pulse, profuse dark 
eruption, and very hiijh temperature. There appeared on the third day threaten- 
ing anginose symptoms. On the fourth these had increased, and, by the night of 
the fifth day, had reached such a height as to make us almost despair of the child's 
life. The violent pharyngeal inflammation was attended with excessive swelling 
of the tonsils, and with cedematous infiltration of the submucous tissue, while ex- 
ternally the cervical glands were enormously enlarged and as hard as paving- 
stones, and the subcutaneous tissues of the front and lateral regions of the neck 
were packed and hard with acute oedema. The general symptoms were most 
threatening. Owing to the swelling of all the parts composing the neck, the res- 
piration was .eo much interfered with as to cause the development of dangerous 
asphyctic symptoms. The pulse, which for the three first days had been running 
at 168, had fallen on the fourth to 140, and on the fifth to 128; the skin was hot 
and dry, and, upon the face, had assumed a dark, bluish tint; there was almo.st 
constant muttering delirium and a degree of tossing and violent jactitation naiirful 
to witness. The swallowing was so much impeded that it was with great difficulty 
that the patient could take the thinnest liquids. Up to this time the case had been 
treated with inunction*, cold drinks, and a febrifuge containing spirit of Minde- 
rerus and sweet .«pirit of nitre. In the midst of these threatening symptoms, and 
when we had almost lost hope, the late Dr. Charles D. Meigs, who saw the case 
with us, proposed abandoning all drucrs, and making use of cold applications ex- 
ternally, and giving stimuli. Accordingly a large towel was wrung out of iced 
water and wrapped around the neck, and weak wine and water was given as often 
as the child could take it. The cloth was dipped afresh into the water every few 
minutes. This treatment wa-" commenced about 1 a.m., and carried on steadily all 
night. At A.M., it was evident that the symptoms had somewhat improved, and 
by the afternoon of that day the patient was greatly better. The improvement 
consisted principally in a moderation of the pharyngeal swelling, so that both res- 
piration and deglutition were much easier. The dark color of the face had les- 
sened ; the pulse had risen in frequoncy, and was stronger; and the delirium and 
excessive jactitation had almost disappeared. On the day after this the external 
cervical swelling continued very much the same, except that the redema had nota- 
bly dlmlnij»hed. The pharyngeal swelling had disappeared, the tonsils having re- 
piined their natural size, but the whole pharynx was covered with a thick mould 
of white exudation. The cold application, which of late had been used more spar- 
J^Rlyi ^»* "o^ discontinued ; the fauces were touched with a solution of nitrate of 
•ilver of ten grains to the ounce; broths, milk, wine-whey, and wine and wat^r 
were given for nourishment, and the patient slowly recovered, after having had a 
Urge suppuration just above the inner end of the left clavicle. 

It was at one time very much the cu.stom to make various application.s 
to the fiiuce*«. Nitrate of silver, pure, or in strong solution, muriatic acid, 
or capsicum, were deemed necew»ary and useful. They have been very 
mach abandoned, and we think wi.sely. The agitation and terror caused 
by them in .some children, and the violent resistance they often make, ex- 
haust the patient, and we therefore avoid them wherever we can. Some- 



760 SCARLET FEVER. 



1 



times, however, and especially in young children, viscous secretions collect 
in the fauces in such quantity as to cause serious annoyance to the child 
and embarrass the respiration : they ought, therefore, to be removed by 
means of a sponge-mop or camel's-hair brush. This point in the treat- 
ment is a very important one, especially in young children. We believe 
that we have rescued more than one patient by going three or four times 
a day to make use ourselves of means by which to remove from the fauces, 
the viscid, glue-like secretions, the purulent fluids, and the masses of 
pseudo-membranous exudation which collect in and occlude those pas- 
sages, and which the child often cannot, by any effort of its own, get rid 
of. The best mode of effecting this object is by the use of mops, made of 
sponge or rag, fastened to a stick or whalebone, or by the injection from 
a small syringe or elastic bottle of detergent washes or gargles into the 
throat, the mouth being held open and the tongue depressed by the handle 
of a spoon. One of the best washes for this purpose is made of a strong 
decoction of green tea containing alum ; or we may employ sage tea and 
alum ; or honey of roses and borax mixed with water; or lime-water; or, 
what is highly recommended by Dr. Watson as one of the best, a solution 
of common salt. Muriated tincture of iron, one part to five or six of 
water, or to one of glycerin and five of water, is an excellent local appli- 
cation. In older children, gargles of salt and water, alum and water, 
chlorate of potash, in claret and water, or plain water, may, and ought to 
be used, when possible. In many cases, even in young children, it is pos- 
sible to secure the inhalation of fluids vaporized by the steam atomizer. 
It will be found that the frequent inhalation of lime-water exerts a very 
favorable effect on the condition of the throat. When coryza is present, 
the nasal passages should be cleansed by means of camel's-hair brushes, 
or by the injection of some of the mild washes just referred to, and then 
freely anointed with sweet oil or some mild ointment, or they may be 
touched with the wash used for the throat. 

Diarrhoea, when present, probably depends on congestion and desqua- 
mation of the intestinal mucous membrane, and should be treated with 
bland demulcent drinks, and absorbent antacids, especially chalk mixture. ' 

Rheumatism should be treated by opiates to allay the pain, and the 
swollen joints should be enveloped in bats of cotton. If suppuration 
should occur, either in connection with the rheumatic inflammation of the 
joints, or involving the glands or cellular tissue, and indicating a pysemic 
tendency, large doses of quinia with stimulants should be given. The ab- 
scesses which may form should be opened so soon as fluctuation can be 
detected. 

For the otorrhcea which sometimes occurs, it is seldom necessary to do 
more during the violence of the attack, than to cleanse the ears twice or 
three times a day, by syringing with warm water and castile soap, or with 
a weak solution of alum. After the violence of the attack has subsided, 
this complication should be treated as in idiopathic cases. 

Treatment of Dropsy. — It is our habit, when directing the general treat- 
ment of a case of scarlet fever, always to explain to the mother or nurse, 
or both, that the most frequent and dangerous sequel to be apprehended 



TREATMENT OF DROPST. 761 

in this disease is dropsy, that this is even more apt to follow mild than 
grave ca^es, and that it usually occurs in the third or fourth week of the 
disorder, though it does occur, on very rare occasions, at a still later period. 
We also assert our belief that this consequence, or complication, or sequela, 
is apt to be produced i)y cold, and that subjects confined to bed through 
the third and fourth weeks, and tliose rigidly secluded in a warm room 
for four weeks from the onset of the disease, no matter how mild the case, 
are much less prone to dropsy than they who leave their beds or rooms at 
an early period to take the usual chances to which children are exposed. 
We know well that Hebra ridicules the stupidity of English physicians in 
ascribing so many disorders to cold. But, whilst we believe with him that 
in p]ngland and amongst ourselves the word " cold " is often used both by 
medical men and by the public as a mere scapegoat to bear the weight of 
their ignorance of the real causes of diseases, we also believe, most em- 
phatically, that chilling of the human body below its natural standard of 
heat, if it be continued for any length of time, is very apt to be followed 
by some disturbance of the health. We are quite sure that we have on 
several occasions, traced a relation of cause and effect between exposure 
to cold in the third or fourth week of scarlet fever and a rapidly sequent 
dropsy. Several such cases are mentioned in the section on the symptoms 
and causes of dropsy, at page 731. W^e always, therefore, urge upon the 
mother or nurse not to allow the child, in the autumn, winter, or spring 
months, no matter how mild may have been the disease, to leave a well- 
warraed and well-ventilated room for four weeks, and, if there be any 
signs whatever of ailing health at the end of the fourth week, to continue 
the seclusion for one or two more weeks. One of the troubles of our pri- 
vate medical career has been the contentions we have had with people in 
their hurry to get children, who have been sick, out of the nursery. In 
gummer weather, this may be all very well, but in the cool and cold months 
it is not very well, as the bills of mortality and the experience of any 
older physician or experienced mother, will show. Why a child should 
lie abed for two or three months for a broken bone, without fear for his 
general health, and yet be regarded as a suffering martyr, because some 
tyrannical doctor insists upon his remaining a few more days or weeks in 
a comfortable chamber, with all the household at his feet, to escape a dis- 
ea.«e like acute Bright's disease, parses our comprehension. 

Before leaving this subject, we wish to say that we have known dropsy 
to follow scarlet fever in one ease, and only in one, io which the child had 
not left the bed. Two children, brother and sister, seven and nine years 
of age respectively, had each a full attack of scarlet fever, — the boy rather 
a severe one. At the end of the third week the boy, being perfectly well, 
WM allowed to leave the bed in a warm room. In two days he was seized 
with scanty, albuminous urine and moderate dropsy. The girl, who had 
fallen sick several days after the boy, and who was small and delicate, was 
kept in bed continuously, and yet she too was attacked with dropsy. Both 
these cases proved very obstinate, and it was several months before they 
were recovered. 

It is important to recognize the renal disease early. The mother should 



762 



SCAKLET FEVER. 



be warned to send for the physician again, if he had resigned the charge 
of the case, should there be any delay or irregularity in the convalescence, 
and especially should she observe any unusual scantiness in the quantity 
of urine discharged ; should this assume a dark and especially a brownish 
or blackish tint ; should there be any fulness of the eyelids, swelling of 
the cervical glands, or, indeed, any departure from a regularly progressive 
return to health. 

In all cases of scarlatinous dropsy, the patient ought to be put to bed at 
once, and kept there throughout the acute period of the disease. The diet 
should be restricted to fluids. Milk and animal broths or farinaceous prep- 
arations alone ought to be allowed. The patient should be encouraged to 
drink freely and often of water, lemonade, or orangeade, or sweet spirit of 
nitre and water. A hot bath, used once or twice a day, is, we think, an ex- 
cellent remedy in the early stage. It is best used in the following mode : 
A portable bath-tub should be brought into the bedroom, if possible. This 
can always be done in the cases of young children. The water ought to be 
warm — 96^^ to 98° or 100°. The patient ought to be fully immersed and 
kept in the water from ten to thirty minutes, the time being regulated by 
the degree of willingness of the child to remain, and by the effect of the 
bath on the system at large, as shown by the countenance and circulation. 
A soft cotton sheet is to be heated at the fire, and in this, when the patient 
is removed from the bath, he is to be carefully wrapped. Over this is to be 
put a light blanket, and thus wrapped in the two coverings, the child is to 
be laid in bed, or held in the arms, for half an hour or an hour. By this 
procedure sweating is generally induced. When this is over, the sheet and 
blanket may be removed and the child dressed in warm bedclothes again. 
The bath, carefully used in this way, once a day in slight cases, and twice 
or even three times in severe ones, has proved in our hands a most useful 
and soothing remedy. 

In mild cases, without fever, the bowels ought to be kept soluble, no 
medicine being needed if they are moved spontaneously. If they are not, 
a little syrup of rhubarb or Rochelle salts will be all-sufficient. If the 
amount of urine is scanty, a diuretic ought to be used. The following 
combination is excellent: 



K.— Potass. Bitart., . 
Spts. Junip. Comp , 
Spts. ^ther. Nitros., 
Syrup. Simp., 
Aq, Fluvial., 

Give a teaspoonful ever 



5J- 

f5v. 
f^ij-M. 



V two hours. 



In more severe cases, when vomiting, fever, anorexia, restlessness, rapid 
anasarca, scanty and dark-colored urine with blood, blood and granular 
casts, and a large proportion of albumen, all demonstrate a serious and 
extensive catarrh of the renal tubules, it is proper to use dry cupping to 
the loins, or in subjects of vigorous constitution, uninjured by the previous 
scarlet fever, we may take three or four ounces of blood from the loins by 
wet cups. If the cupping cannot be used, hot cataplasms of Indian mush 



PROPHYLACTIC TREATMENT. 763 

or flaxseed or bags of hot sand should be applied from time to time over 
the loins. The bowels oujrht to be kept open by rhubarb, Rochelle salts, 
or Seidlitz powder. A febrifuge and diuretic, such as the following, must 
be used ; 

R. — Potass. Acetat., ,^j. 

Tinct. Dijjitalis, f:;?s. 

Syrup. ScilK-^, f::^] vel f^ij. 

•' Zingib., f^y. 

Aqux, ....... ad f5iij. — M. 

Give a toaspoonful every two or three hours to children two or three years old. 
For those above that age the proportion of the active ingredients should be doubled. 

By these means the case should be treated for several days, until the 
fever subsides and the patient is no longer in present danger. When the 
fever is over, it is best to continue the above mixture, or something of the 
same kind, at longer intervals, and to give also one of the preparations of 
iron. Our own favorite is the mixture of muriated tincture of iron with 
acetic acid and spirit of ]\rindererus, or the simple tincture itself, in doses 
of from two and a half to five drops, according to the age, three or four 
times a day. If from any cause the tincture cannot be taken, wine of iron, 
or ferrated elixir of Calisaya bark, may be substituted, in half-drachm or 
drachm doses. 

As the fever disappears, the food ought to be increased. This is, of 
course, more important than drugs, and ought to be strictly attended to by 
the physician himself at each visit. In some instances the most perverse 
irritability of the stomach attends the case for several days, so that the 
patient may almost or actually die of exhaustion. In such cases it is 
worse than folly to give drugs which are resisted with loathing, and 
vomited the instant they enter the stomach. Something must be chosen 
which at lea.st does not clearly cause vomiting by its smell or taste. A 
mixture of wine of iron with syrup of Tolu and some aromatic water, 
chocolate of iron lozenges, or powdered metallic iron with white sugar, 
can often be taken even in these ca.ses. A weak cream of tartar lemonade, 
flavored with lemon-juice, sweet spirit of nitre in lemonade, watermelon- 
seed tea, and such remedies may be used. In regard to details, as to the 
best method of feeding in such ca.ses — on which, we desire to say, much 
more depends than upon drugs — we mu.st refer the reader to the remarks 
on diet in obstinate sick .stomach in chronic diarrhrea. We venture to 
hope that we have seen lives .'<aved in ca.ses of this kind by constant at- 
tention to little details of food and medicine, which must have been lost 
by any less constant care. In one instance the child was almost comatose, 
with total suppression of urine for five days, and the stomach so irritable 
that no remedy .scarcely could be borne. Finally, under small doses of 
watermelon -seed tea, given frequently, mustard foot-baths, blisters behind 
the ears, and feeding with lime-water, milk and brandy, wine whey, chicken 
tea, and such preparations, the patient recovered. 

Prophylactic Treatment. — It was formerly asserted that hr/ladonna, 
used by j)ersons exposed to the contagion of scarlet fiiver, had flu power 



764 MEASLES. 



% 



of imparting perfect or nearly perfect immunity from its attack. The 
evident difficulty of determining a question such as this, in reference to 
a disease so uncertain and irregular in its mode of extension as scarlatina, 
long maintained a certain degree of doubt as to the possibility of the truth 
of this most unlikely assertion. We believe, however, that by common 
consent, all belief in the supposed efficacy of belladonna for this purpose 
has now been abandoned. 

Dr. Brakenridge (Medical Times and Gazette, July 24th, 1875, p. 92) 
has given sulphocarbolate of sodium in doses varying, according to age, 
from five to thirty grains three or four times a day, to those exposed to the 
poisons of scarlet fever, diphtheria, and measles ; and, although not feeling 
that his observations have proved the power of this treatment to prevent 
attacks of these diseases, he is inclined to attribute some prophylactic power 
to it. 

In order to purify articles which have been exposed to scarlatina, they 
should be either put in boiling water or exposed to a temperature of over 
200°, as we have seen that a temperature somewhat below the boiling-point 
of water destroys the activity of the virus. 



AKTICLE VII. 

MEASLES, RUBEOLA, OR MORBILLI. 

Definition; Frequency ; Forms. — Measles are an epidemic and con- 
tagious exantheru, characterized by catarrhal symptoms, continued fever, 
and an eruption, generally on the fourth day, of a crimson rash, in the 
form of stigmatized dots, like flea-bites, slightly elevated, which coalesce 
into irregular circles or crescents. It ends about the seventh day by des- 
quamation. 

The frequency of the disease is very irregular in different years, because 
of its epidemic nature. Thus, according to the mortality tables of the 
Board of Health, there have been 2279 deaths from measles in this city 
during the sixty years ending with 1870. In five of these years, as will 
be seen by a reference to the table at page 702, there is not a death recorded 
from this cause, while, on the other hand, the annual mortality exceeds 
100 in eleven years, and 200 in two. During the same period, the deaths 
from scarlatina in this city, as already stated, amounted to 13,016. 

Measles are probably a more common though a less fatal disease, and 
attack a larger number of persons than scarlet fever ; thus, during a period 
of fifteen years, during which we noted every case that occurred in our 
practice, we met with 314 cases of the former to 263 of the latter. 

We shall describe two forms of the disease ; the regular or rubeola vul- 
garis ; and the mfilignant or rubeola maligna. We shall afterwards treat 
of its irregularities and complications. 

Causes. — A chief cause of the disease is epidemic influence. Of this 
there can be no doubt, as it is proved by the evidence of all observers. 



CAUSES. 765 

Contagion. — That it is a contagious disease is universally admitted. The 
contairious quality is thought to begin with tlie primary fever, and to con- 
tinue up to the period of desquamation, thougli some authorities believe 
that it is also contagious during the stage of incubation. The precise 
period at which it ceases is not, however, known. The disease may be car- 
ried in fomites. It has been propagated also by inocuhition witli the blood 
taken from a patient, and witli serum obtained from the vesicles which 
sometimci? accompany the eruption. 

The period of incubation is difficult to determine, but is usually stated 
as from five or six, to twenty days, or even longer. In the great majority 
of cases, however, the eruption appears in from twelve to fifteen days after 
expo.-;ure to the contagion, thus making the duration of the period of incu- 
bation from nine to twelve days. Thus, in 12 cases where we were able to 
determine with precision the interval between the exposure to contagion 
and the appearance of the rash, it was ten days in 1 case, eleven in 1, 
twelve in 3, thirteen in 5, fourteen in 1, and fifteen in 1. In 108 cases 
observed by M. Girard, of Marseilles (quoted in 3Ied. Times and Gaz., 
Aug. 21, 1869, p. 225), the eruption appeared as late as the sixteenth day 
only in 3 cases; in all the others it was developed on the thirteenth or 
fourteenth day, never before the thirteenth, and never after the sixteenth. 

MM. Rilliet and Barthez conclude that measles are more frequent, less 
contagious, and have longer incubative and prodromic stages than scarlet 
fever. 

The same authors are of opinion that variola is somewhat more rare, 
rather more contagious, and that its period of incubation and its prodromic 
stage are a little shorter than those of measles. 

Measles, like other contagious diseases, rarely occur a second time in the 
same individual. We have, however, met with undoubted cases of second 
attacks ; although unquestionably in a large proportion of the numerous 
cases in which we have been told that two attacks had occurred, one of 
them had been not of true measles, but of Witheln or roseola. 

Age. — We find by uniting Dr. Emerson's tables with some given by Dr. 
Condie (Dis. of Child.y note, p. 100), that the disease appears to be most 
frequent between the age of one and two years, for while 395 deaths 
occurred in the second year, only 468 occurred between two and five years 
of age. This does not agree, however, with our own experience, since of 
280 cases of the disease that have come under our own observation, in 
which the age was accurately recorded, only 36 occurred in the second 
year, while 84 occurred between the end of the second and the end of the 
fifth year. This di.screpancy depends probably, in part at least, on the 
greater mortality of the disea.se during the earliest years of life, which 
would of course give a larger number of deaths for those attacked in the 
second, than for thf«e in the third, fourth, and fifth years. The ca«e.s that 
have come under our own observation occurred as follows. They arc 
stated in their order of frequency. In the sixth year, 37 ; in the necond, 
36; in the seventh, 35; in the fifth, 34; in the fourth, 30; in the eighth, 
27; in the first, 19; in the ninth, 11 ; and then in the eleventh, tenth, 
thirteenth, twelfth, and fifteenth. 



766 MEASLES. 

Sex. — It appears to be more common in the male than in the female sex. 
Of 290 cases that we have seen, in which the sex was noted, 156 occurred 
in males, and 134 in females. 

Fungous origin, — In 1862, Dr. Salisbury, of Ohio (Am. Jour, of Med. 
Sciences, July and October, 1862), published two elaborate articles, in 
which he attributed measles to the action of the fungus developed on damp, 
mouldy straw. He reported the results of numerous cases in which this 
fungus had been inoculated, with the production of a modified form of 
rubeola, which, however, protects the system against a future attack of true 
measles ; and also instances where measles had broken out in camps where 
damp straw was used for bedding. 

A complete examination of this question, embodying the evidence of Dr. 
Woodward {Camp Diseases of the U. S. Armies, Philadelphia, 1863), and 
the experiments of Dr. C. E. Smith, and one of ourselves, will be found in 
a paper by Dr. H. C. Wood, Jr., in The American Journal of the Medical 
Sciences, October, 1868, p. 342. 

The results of the inoculation of nearly 50 cases, prove that in nearly 
every instance, the iutroduction of the straw fungus into the system is 
entirely without effect ; and that in the few cases where any symptoms 
have followed, they have not been those of true rubeola, nor have they 
protected the system from an attack of genuine measles. 

In regard to the occurrence of camp measles also. Dr. Woodward re- 
marks, that it prevailed almost exclusively in regiments raised in the rural 
districts, while those from cities and towns were more or less completely 
exempt ; and that the inevitable inference from this, confirmed by personal 
inquiry, is that the recruits from the country had generally escaped the 
disease before their enlistment, while those from towns had usually suffered 
from it at some previous period ; a condition of things entirely at variance 
with the idea that the straw fungus is the veritable cause of measles. 

Symptoms ; Couese ; Duration. — Regular form of the disease. — Stage of 
invasion. — Measles begin with languor, irritability, sometimes chilliuess, 
anorexia, aching in the back and limbs, fever, thirst, headache, and 
various signs of irritation of the mucous membrane of the eyes, nose, 
fauces, and larynx. 

The chilliuess or horripilations which are mentioned by almost all 
writers are difficult to appreciate in children. We have seldom known 
the child itself to complain of them, but upon inquiry of the mother or 
nurse, have sometimes been told that they had observed some coolness 
of the hands or feet, or a disposition to keep near the fire, and a desire 
for additional clothing. These, therefore, are not important symptoms. 
Neither is the aching in the back and limbs, as it is seldom complained 
of, and can be ascertained in the older only by close questioning, or sus- 
pected in the younger by their complaining when they are moved. Fever 
is very rarely absent. It almost always comes on with, or very soon after 
the other prodromes, but in rare cases does not begin until the second day. 
It is almost invariably continued, after it once begins, except that it remits 
somewhat about daylight and in the early part of the morning, to become 
exacerbated again in the after-part of the day. Its intensity increases, and 



I 



SYMPTOMS. 767 

the remissions become less distinct and shorter, as the time for the appear- 
ance of the eruption approaches. The pulse is increased in frequency, 
force, and volume, but rarely attains the same rapidity as in scarlet lover. 
At the same time the skin becomes warm and dry, the face is generally 
flushed, and there is considerable restlessness and irritability at first, often 
passing into quiet and drowsiness as the eruptive point approaches. The 
fever is accompanied by thiist, partial or com])lete anorexia, and generally 
by headache, which is frontal, and often complained of by children old 
enough to give an account of their sensations. 

Vomiting occurs sometimes, but not as a general rule. The catarrhal 
symptoms commence with, or may even precede the fever. They consti- 
tute the most characteristic early symptoms of the disease, and indeed the 
only ones by which we are able to distinguish it with any certainty in the 
first stage. They consist of irritation and redness of the conjunctivae, 
especially that of the eyelids, lachrymation, suffusion of the eyes, sensi- 
bility to light, stuffing of the nose, coryza, sneezing, slight soreness of the 
throat, cough, some constriction of the thorax, and slight dyspnoea. The 
state of the eyes and nose are very important as signs of the disease. The 
above symptoms are not always present in the same degree, being very 
strongly marked in some instances, in others less so, and in some rare 
eases, absent. They are important, because there are few cases of ordi- 
nary cold in which they are present to the same extent, or if so, the ac- 
companying general symptoms are slight compared with those of measles. 
We have rarely known the faucial atfection severe enough to elicit com- 
plaints, and never to produce difficulty of deglutition. It consists gen- 
erally only of slight redness of the tonsils, soft palate, and pharynx, which 
is most strongly marked about the time that the eruption makes its ap- 
pearance. The cough usually appears on the first day. Infrequent and 
slight at first, it becomes more troublesome as the case progresses, until it 
assumes, on the third or fourth day, a character which is peculiar, and 
which may often lead to a suspicion as to the true nature of the attack. 
It is laryngeal, hard, dry, rather hoarse, and occurs generally in short 
paroxysms. Expectoration, if present at all, is slight, and consists of a 
clear, viscid mucus. At the same time the voice is often hoarse. 

The tongue is usually white and somewhat furred ; the bowels remain 
in their natural condition, or there may be slight consti])ation or diar- 
rhoea. Constipation is most frequent, according to our own experience. 
The drowsiness, to which we have already alluded, often exists during the 
first stage. We have noticed it in a great many cases. The child, if un- 
disturbed, sleeps quietly for many hours, or for the greater part of one or 
two days, waking only from time to time to ask for drink, and then sink- 
ing ofl' to sleep again. So common is this symptom that old nurses have 
a saying, — "The child is sleeping for the measles." The symptom is not 
alarming, unless it be connected with others which indicate local disease, 
or unless it pass into coma, or alternate with marked delirium. Other 
nervous symptoms which sometimes occur, especially when the fever is 
violent, are restlessness, irritability, occasionally delirium at night, and, in 
very rare cases, convulsions. Of 167 cases observed by Killiet and liar- 



768 MEASLES. 

thez, the latter symptom appeared in the first stage only in one, and was 
then confined to the eyeballs. We have met with convulsions in 5 out of 
314 cases, at the beginning of the eruption, and in one, of which we shall 
not now speak, at the close of the eruption. In one of the cases the con- 
vulsions occurred on the first day, in a boy five years of age, of nervous 
temperament, and who had had several convulsive attacks during the 
process of dentition. The convulsions were general, but slight ; they 
lasted only a short time, and were not followed by any bad consequences. 
In the seeond case the sickness began with fever, drowsiness, tremulous 
movements of the hands, delirium, and in a few hours a slight general 
convulsion. On the second day there were two attacks of convulsions, 
both, however, slight. The other symptoms continued as before. On the 
third day the child was better, the fever having diminished, and the ner- 
vous symptoms in great measure disappeared. On the fourth, fifth, and 
sixth days, the fever returned, and on the middle of the sixth day, a full 
measles rash made its appearance. There was no recurrence of the ner- 
vous symptoms, and the case ended favorably. The third case occurred 
in a boy between seven and eight years old, of nervous and impressible 
temperament. The convulsive seizure took place just as the rash was com- 
ing out ; it was very slight, and lasted not more than one or two minutes. 
In the fourth case, in a boy in the second year of life, who had already 
had three convulsive attacks from other causes, showing thereby a mani- 
fest predisposition to that kind of disorder, the convulsions occurred as in 
the previous case, just at the coming out of the eruption. In this case also 
the convulsions were slight, lasting only a few minutes. In neither of 
these two cases were the convulsions followed by dangerous symptoms. In 
the fifth and last case, the convulsions, as in the two preceding examples, 
occurred just as the rash was appearing; they were very slight, and were 
followed by no serious consequences. The subject of this case was a girl 
between seven and eight years old, who had previously had an attack of 
convulsions produced by a severe febrile reaction occasioned by simple 
angina, and another attack, caused by indigestion. 

MM. Guersant and Blache (Did. de Med., t. 27, p. 658) mention another 
initial symptom, which has sometimes enabled them to recognize the ap- 
proach of measles before the eruption. This is a peculiar redness, a rose- 
colored punctation, of the roof of the mouth, soft palate, and uvula, dif- 
fering from that of scarlatina. We have observed this symptom ourselves 
in quite a number of cases, and, as it not unfrequently appears twenty-four 
hours before the cutaneous eruption has come out, we think that it is of 
some value as a sign in the early stages. 

M. Girard (loc. cit.) states that the early diagnosis may be aided by the 
fact, that a red papule appears near the free border of the velum palati 
several days before the appearance of the eruption. 

The duration of the initial stage is generally from three to four days. 
In a large majority of the cases that we have seen, the eruption has begun 
to appear in the course of the fourth day. This stage may, however, last 
only one or two days, or be prolonged to five, six, or seven, and according 
to Guersant and Blache {loc. cit, p. 659), it lasted in one case, with all the 



SYMPTOMS. 769 

characteristic symptoras, fifteen days. In a case that occurred to one of 
ourselves, the subject of which was a ffirl between one and two years oUl, 
the eruption, owing no doubt to the presence of severe general bronchitis, 
did not make its appearance until the ninth day of the sickness, and even 
then came out slowly and with much difficulty. The disease was known 
to be approaching from the fact that another child in the house had just 
recovei-ed from an attack. In another case, in a girl between twelve and 
thirteen years of age, the eruption began on the fourth day of the sickness, 
but was so faint and indistinct that we could not, until the sixth day, feel 
sure that it was a measles rash. Even after this, the eruption continued 
pale and insufhcient until the seventh day of the eruption, when it was out 
fully and completely. 

Second Stage, or that of Eruption. — The eruption generally appears some 
time in the course of the fourth day, showing itself first on the chin or 
cheeks, or some other part of the face, and extending gradually to the 
neck and trunk, and finally to the extremities. It is often completed in 
from twenty-four to forty-eight hours. It begins in the form of distinct 
spots, not unlike flea-bites, of a more or less bright rose or crimson color, 
verging sometimes towards a deep red, of a roundish shape, with irregular 
edges, and of different sizes, varying between half a line and three lines in 
diameter. When fully formed they constitute true papules, which are felt 
to be slightly elevated and firm to the touch, with broad flat summits. 
When pres.sed upon, their color disappears, to return rapidly when the 
pressure is removed. Distinct and scanty at first, the spots or stigmata 
soon become more numerous, and arrange themselves into clusters of an 
irregularly crescentic or semilunar shape. The number of these clusters 
and tlte consequent general tint of the skin, depend upon the amount and 
intensity of the eruption. In very mild cases, or when the eruption is 
imperfect, the clusters of papules are few in number, and they are sepa- 
rated by large portions of healthy skin. In severe cases, on the con- 
trary, the patches are so numerous, and coalesce so closely, that the skin 
assumes a general deep-red tint. Occasionally in these severe cases mi- 
nute vesicles form on the summit of the papules. Yet it ought to be 
remarked that it can be observed on close examination that the papules 
never run completely into each other, so as to form a continuous red sur- 
face, unless it be over very small spaces and on certain parts of the surface, 
more particularly the face. 

The fever does not dimini.sh when the eruption makes its appearance, 
and it sometimes augments, so that the highest temperature of the attack 
is usually attained soon after its full developnjcnt. The skin retains its 
heat; the irritation of the eyes continues and is sometimes very severe; 
the nostrils are dry and iucrusted, or there is coryza, and in some few 
cases epistaxis. The face b at the same time flushed, independently of 
the eruption, the red color of the skin being observable in llu* intervals 
between the papules, and it lof)ks swelled and turgid, from tumefaction of 
the cheeks and particularly of the eyelids. The cough continues, and is 
loud, hoarse, and frequent in most cases, but in others short, scarcely 

49 



770 MEASLES. 

hoarse, and but slightly marked. The voice is usually but not always a 
little hoarse. The respiration is slightly quickened in regular cases, but 
generally very little beyond the natural rate. The pulse is accelerated, 
though to a less degree than in scarlatina ; its frequency is usually found 
to be in direct proportion to the height of the temperature. The tongue 
is covered with a yellowish or whitish fur in its middle, while the edges 
and tip are clean and red. It remains moist and soft unless some compli- 
cation occurs. The tonsils, soft palate, and pharynx, present considerable 
redness, without tumefaction. The abdomen commonly remains natural, 
though in some few cases there is slight soreness over its whole extent or in 
the iliac fossae. Slight diarrhoea often occurs at this time. It seldom lasts 
more than from one to three days. In other cases the stools are natural, or 
there may be moderate constipation. The anorexia and thirst continue up 
to the stage of decline. About the time of the appearance of the rash there 
is often considerable restlessness, anxiety, starting and twitching in sleep, 
slight delirium, and in children old enough to describe their sensations, com- 
plaints of headache. The strength of the patient is not decidedly affected 
in most of the cases. 

The urine during this stage is scanty, of dark-yellow color, and not 
rarely contains a trace of albumen. 

Stage of Decline and Desquamation. — The disease having reached its 
height in the course of the sixth day, the second of the eruption, it re- 
mains nearly stationary for one or two days longer, and begins to subside 
about the seventh or eighth of the disease, or third or fourth of the erup- 
tion. The eruption fades first on the face and neck, and has often very 
much or wholly subsided on those parts while it is still vivid on the ex- 
tremities. The papules lose some of their color, become less prominent, 
diminish in size, and when pressed upon do not disappear entirely as they 
did at first, but leave a dull or yellowish stain behind. A little later they 
assume a dirty yellow or copperish tint, which does not disappear under 
pressure, showing that a slight ecchymosis has taken place into the sub- 
stance of the derm. These stains continue a variable length of time, and 
are finally removed by absorption. As the eruption disappears, a slight 
furfuraceous desquamation takes place in a considerable number of the 
cases, but not by any means in all. This begins usually about the face, 
and may either be limited to that part, or extend to other portions of the 
body. It is seldom general, however, and is often scarcely noticeable. It 
occurs between the eighth and eleventh days of the disease, or fourth and 
seventh of the rash. 

From the moment the eruption passes its highest point of intensity, and 
begins to decline, the other symptoms do the same. The pulse fast loses in 
frequency, and regains its ordinary characters. The heat of skin passes 
away, often with considerable perspiration, but sometimes with gentle mois- 
ture only. The various catarrhal symptoms subside; the cough is less 
frequent, loses its hoarseness, becomes softer, and gradually ceases. The 
expectoration, if present, now becomes more copious and thinner, and pre- 
sents nummular masses of muco-purulent matter floating in a clear, watery 
fluid. The tongue cleans off"; appetite returns ; thirst ceases ; the restless- 



TEMPERATURE — IRREGULARITIES. 771 

ness and irritability disappear; and the child returns to its ordinary con- 
dition of health. 

Temperature. — According to the observations o( Ringer {Reynolds's Syst. 
of Med., vol. i, art. ^[easles\ the highest temperature reached in ordinary 
cases is about 103^ F. From the observations of Roger (o]k cit., p. 298) 
this would appear higher than is usually attained, the mean of his records 
having been only 101.5^ F. If it rises above 102.5° it indicates a severe, 
if it continues below this, a mild attack. The temperature presents the 
diurnal variations usual in fevers, until the close of the disease, when it 
suddenly declines. The duration of measles, measured by the temperature, 
varies considerably ; the decline of the fever occurring in some cases on the 
fourth day, in others not until the eighth or tenth day. 

Irregularities of the Disease. — Under this term we shall describe 
only the anomalous symptoms of the disease, which occur independently 
of complications. Those which are produced by the latter causes will be 
fully treated of when we come to consider the subject of the complications. 

In some cases, the symptoms of the prodromic stage are so slight that 
they pass almost unobserved, and the child is scarcely thought to be sick 
until the rash makes its appearance. In others, owing to some peculiarity 
of the temperament, or to the state of the constitution at the time, they are 
much more severe than usual, or some one symptom may be in excess. In 
one case that came under our own observation, in a girl seven years old, 
the nausea and vomiting were very distressing, and were accompanied by 
the most intense frontal headache. She complained precisely as children 
generally do with tubercular meningitis, and was, moreover, extremely 
restless, and at night delirious. Nevertheless, the eruption came out on 
the fourth day, and was perfectly regular in its characters and course ; the 
unpleasant symptoms ceased from that moment, and the patient recovered 
without any further bad sym})toms. We have already spoken of five cases 
accompanied by general convulsions at the commencement of the first stage. 
The course of the disease in the subsequent stages was regular in all re- 
spects. In two other cases, in girls, sisters, seven and nine years old re- 
spectively, of highly nervous temperament, the headache in the first stage 
was so intense as to require the application of leeches for its relief; yet the 
disease was regular in its other characters. 

The eruption presents various irregularities which ought to be noticed. 
It has already been stated that the amount of the rash varies according to 
the severity of the case, although in other respects regular. Sometimes 
the papules are comparatively small in size and few in number, and con- 
sequently, the clusters in which they are arranged have considerable spaces 
of healthy skin between. When this is the case, the stigmata are usually 
rough, lighter in color, and from this circumstance and the fact that the 
spaces between the clusters are large, the general tint of the skin is much 
less deep than in severer cases, in which the opposite of these fliaractera 
prevails. In some of the mildest cases, the amount of enq)tion upon the 
extremities has been very small, and after forming, it has very rapidly, in 
the space of a night, faded to such a degree as to seem almost a retroces- 
sion. But as this sudden disappearance has not been accompanied or fol- 



772 



lowed by dangerous symptoms, it is clear that it was dependent simply on 
the raihiness of the attack. In such instances the general symptoms have 
always been slight, and the whole duration of the sickness shorter by two 
or three days than in severer cases. At times the order of appearance of 
the eruption is reversed, and the papules appear first on the trunk, thence 
spreading to the face. 

We have already described the dull yellowish stains which remain after 
the papules have faded. These stains sometimes assume, in malignant 
cases, a livid or purplish hue, from the occurrence of passive haemorrhage 
into the tissue of the derm. They may, however, assume a dark and 
purpureous appearance, without any malignant or dangerous symptoms 
whatever. This happened in a family in which one of us attended seven 
cases of the disease in 1845. In three of them (boys of 10, 5, and 1 year 
old, respectively), the eruption, which was copious and regular in all, be- 
came in a single night, at the moment of decline, of a dark-brown or light- 
purple hue. The spots did not disappear at all under pressure, and were 
evidently formed by true ecchymoses. The general symptoms were all 
favorable. The only peculiarity to be observed was that the fever had 
disappeared very suddenly, and that the extremities were slightly cooler 
than natural. The convalescence was as usual, except that the ecchymotic 
spots disappeared very slowly and gradually. We have, since the above- 
named period, seen a great many similar cases, but in none have the symp- 
toms been attended or followed by any evil consequences. 

Several authors describe a form of measles without eruption. They 
state that during the epidemic prevalence of the disease, some children 
present all the catarrhal and febrile symptoms, without the eruption, and 
that they are protected against future attacks. The last assertion, at least, 
must be very difficult to prove. For our own part, we have never met 
with such cases, and should we ever seem to do so, would certainly not 
call them measles, lest by so doing the parents might be induced, on future 
occasions, to expose the child unnecessarily to the disease, when, should 
any evil consequences follow, they might justly question the wisdom of the 
physician's advice. 

Willan and other authors have described another variety of the disease, 
to which is applied the term rubeola sine catarrho, or measles without 
catarrhal symptoms. Such cases are said to present no catarrhal symp- 
toms whatever, and little or no febrile reaction. They are stated, more- 
over, to occur generally during the epidemic prevalence of measles. Most 
authors agree that this form does not protect the constitution against the 
true disease, and some regard it only as an eruption resembling measles, 
dependent upon gastric disorder. Our own opinion is that such cases, of 
which we have seen a considerable number, are nothing more than ex- 
amples of roseola. The entire absence of catarrhal symptoms and of fever, 
or their very slight character, the short duration of the cases, and the little 
constitutional disturbance exhibited by the patient, all serve to convince 
us that they cannot be attacks of true measles. We recollect three such 
cases in particular, which, had they been accompanied by cough and fever, 
we should certainly have called measles. They all occurred in infants. 



MALIGNANT FORM — COMPLICATIONS. 773 

The rash was preceded for t\v(^ or three days by feverish uess, uneasiness, 
restlessness during sleep, and slight diarrhcva, after whieh the eruption 
suddenly made its appearance and covered the whole integument within 
twenty-four hours. There were no catarrhal symptoms whatever. At the 
t»ame time the febrile symptoms disappeared, and the children seemed 
quite well. The eruption never lasted over forty-eight hours, and disap- 
peared without leaving a trace behind. They were, no doubt, cases of 
roseola. 

Rubeola Maligna. — This form may occur either as an epidemic or 
sporadic affection. Generally, however, it prevails as an epidemic, and 
depends upon some peculiarity which it is impossible to understand. The 
few sporadic cases which are met with, may be traced generally to some 
vicious state of the constitution of the individual, or to the unfavorable 
hygienic conditions in which he is plaoed. The symptoms assume ataxic 
or adynamic characters, which give to the case the features of the typhoid 
type of disease. They may make their appearance in the prodromic, or, 
as happens more frequently, not before the eruptive stage. "When they 
begin in the first stage, the case is marked by great frequency and feeble- 
ness of the pulse ; by prostration ; by unusual dyspnoea and oppression ; 
and especially by greater violence of the nervous symptoms, as delirium 
or stupor. Sometimes, even in this stage, petechia? make their appearance, 
and there is lividity and soreness of the fauces, with discharges of dark 
blood from the nostrils, and sometimes profuse and exhausting diarrhiva 
or dysenteric discharges. When the time for the eruption to appear ar- 
rives, this comes out slowly and imperfectly, or irregularly, and generally 
assumes a livid, purplish, or blackish color, owing to the passive exuda- 
tion of blood into the papules, and hence the name sometimes given to 
such cases, of Rubeola Nigra, or black measles. 

This form of the disease assumes, in fact, many of the features of pur- 
pura ha?raorrhagica. The patient may die of exhaustion, of congestion 
of some important organ, as the brain or lungs, of the diarrhoea or dys- 
entery which sometimes complicate the disease, or finally of the h:emor- 
rhages which occur in consequence of the dissolved and fluid state of 
the blood ; or he may, after a severe struggle with the disease, recover his 
health. 

Complications and SKQUELiT:. — MM. Rilliet and Barthez begin their 
chapter on the complications of this disease with the following excellent 
remarks: "Rubeola manifests itself by an inflammation or inflammatory 
fluxion upon the skin and mucous membranes. The regular course of the 
disease depends upon the conservation of a due equilibrium between these 
two kinds of fluxions. That which is seated in the skin ought in general 
to predominate: if the equilibrium be destroyed by any cause whatever, 
whether accidental or inherent to the disea.«e, and should the predominance 
of the inflammation take place in the mucous membranes, there will result 
a phlegmasia of some one of those tissues. 

" It is easy to foresee, by attention to these circumstancea, that the inflam- 
mator}' complications of measles will be most apt to fall upon the mucous 



774 



membranes, and that broncho-pneumonia, pharyngo-laryngitis, and intes- 
tinal inflammations will be the most frequent of all." 

Bronchitis and Pneumonia. — These constitute by far the most frequent 
and important complications of measles. In 167 cases, MM. Killiet and 
Barthez met with 24 cases of bronchitis, 7 of pneumonia without bron- 
chitis, and 58 of lobular broncho-pneumonia. This statement shows how 
very large a proportion of the cases of measles occurring in the Children's 
Hospital at Paris, became complicated in the course of the attack. The 
proportion in private practice is much smaller, since in 314 cases, we have 
met with only 24 of bronchitis, and 6 of lobar pneumonia. These are, 
however, in private practice, according to our experience, much the most 
important of the complications likely to occur. Of six deaths which oc- 
curred in the 314 cases that we have seen, 3 were caused by bronchitis. 

The time at which these different complications make their appearance 
is importai^it. They may occur during the initial stage, early in the erup- 
tive stage, during the decline of the eruption, or after the eruption. The 
most common period for their occurrence is the initial stage. It is difficult 
or impossible to ascertain their causes in a great many cases. In some 
instances they depend evidently upon cold. Age has some influence upon 
their production, as bronchitis is most apt to occur in young children, 
whilst lobar pneumonia attacks those who are older. 

The physical signs of these affections are the same as when they exist 
in the idiopathic form. The rational signs are increase of cough, which, 
instead of being merely laryngeal, becomes deeper and either pneumonic 
or catarrhal ; and dyspnoea, which is sometimes excessive, the number of 
respirations mounting to 40, 50, and, in severe cases, to 60 and 80. The 
pulse is more frequent than in regular measles, and in very bad cases be- 
comes rapid and small ; the skin is hot and dry ; the face is pale and 
anxious in severe cases, in which the eruption does not appear ; and the 
child is generally restless and irritable, with broken irregular sleep, or, in 
the most violent cases, it is dull and soporose. In two of the fatal cases 
that came under our observation, convulsions occurred. It should be re- 
marked, however, that in one, the patient, a boy only nine months old, 
was laboring under an attack of hooping-cough, and that it was in one of 
the paroxysms of that malady that death took place. In the other case, 
that of a boy eighteen months old, the convulsions occurred first on the 
day of eruption, and then ceased, to recur again the third day afterwards. 
The bronchitis dated from before the appearance of the eruption, and was 
no doubt the cause of the convulsions and death. 

When a pulmonary complication begins in the prodromic stage, it almost 
always modifies the eruption in some manner, either retarding or render- 
ing it irregular or imperfect. When it dates from the second stage, it may 
cause a partial or complete retrocession of the eruption. We have known 
the eruption to be retarded several days, so as not to come out until the 
fifth, sixth, or even ninth. When the rash does appear, whether at the 
usual period or later, it is evidently with difliculty. It is pale and scanty, 
or abundant on one part of the body, and scanty on another, or it appears 
and disappears alternately. At length it either comes out fully, and the 



COMPLICATIONS. 775 

threatening symptoms pass away, or the eruption hists the usual, or 
nearly the usual length of time, in its pale and imperfect condition, and 
the child recovers slowly and gradually from the complication, which 
has become the most important part of the sickness; or, in fatal cases, 
the symptoms grow worse and worse, and the chihi dies after a few days, 
or a longer time, according as the inflammation assumes the acute or 
chronic type. 

Whenever it is observed in a case of measles, that there is more drow- 
siness or irritability than usual, or that the pulse is more frequent or 
stronger than it ought to be, it becomes important to ascertain carefully 
the state of the respiration. If this be accelerated, the thorax ought to be 
examined with strict attention, by auscultation and percussion, to discover 
whether there be not some pulmonic inflammation at work, likely to con- 
vert the disorder from a mild one, as it almost always is when uncompli- 
cated, into one dangerous to life, which it will assuredly become, should 
any pulmonic complication be allowed to steal unawares upon the patient. 

The prognosis of the pulmonic complications of measles would appear 
to be very unfavorable in hospitals for children, since Rilliet and Barthez 
state that scarcely one patient in four or five recovered. Of the 30 cases 
that we have seen, we have already stated that 3 died of bronchitis, and if 
we recollect that one of these was complicated also with pertussis and 
morbid dentition, it will be seen that the prognosis is, as might be expected, 
vastly more favorable in private than in hospital practice. 

There is, however, a tendency, especially marked in delicate, strumous 
children, for the inflammation of the bronchial mucous membrane to be- 
come chronic, in which case the cough may persist for years, at times in- 
termitting, but returning after the slightest exposure, and particularly in 
cold, damp seasons of the year. 

LnryngitU is a common complication of the disease. The authors just 
quoted met with it in 35 of their 167 cases. It occurred in 8 of the 314 
cases that came under our observation. It is often accompanied by phar- 
yngitis. 

Autopsies show that the laryngitis may be slight, severe, or accompanied 
with pseudo-membranous exudation. The inflammation may be sim|)le, 
coDsi.sting merely of diff*erent degrees of redness, or of rednass with thick- 
ening and softening of the mucous membrane; it may be more intense and 
accompanied by ulcerations or erosions ; or, lastly, it may be associated 
with an exudation of false membrane. 

The symptoms of this complication will depend upon the form the in- 
flammation a-ssumes. It is unnecessary to describe them here, as they are 
the same as those of the idiopathic aflTection, which has already been fully 
treated of. 

The occurrence of laryngitis exerts but little influence on the rash, par- 
ticularly as it almost always appears during the decline of the latter. It 
is seldom fatal, unless it assumes the p.^udo-membranous form. The eight 
cases that came under our observation were attacks of the simple disease, 
and they all recovered. 

Inflammation of the LUestijies. — According to Uilliet and Barthez, lesions 



776 MEASLES. 

of the intestinal mucous membrane are the most frequent complications, 
after pulmonary affections. About a third of their cases presented at the 
autopsy erythematous inflammation of the mucous membrane ; a fifth 
offered follicular entero-colitis, a seventh ulcerative inflammation, and a 
fourth softening. Some presented several of the lesions united, and in a 
few no lesion was found, though the symptoms of entero-colitis had existed 
during life. We give these data from the above authors, not because they 
apply to private practice, but merely in order to show what are the tenden- 
cies of the disease, when disposed from unfavorable hygienic conditions to 
take on complications. We have met with only seven instances of intes- 
tinal inflammation in the 314 cases that have come under our own obser- 
vation. Four of these occurred in the same family, in children of seven, 
five, three, and one year old respectively. They were cases of entero-colitis, 
accompanied in two, with dysenteric symptoms, and all made their appear- 
ance towards the close of the disease. The three remaining cases were 
attacks of dysentery, one of which was very severe, the stools amounting 
to twenty in the day, while the other two were much less so. 

The intestinal complications may appear during the initial stage, or on 
the day of eruption, but if not at one of these periods, they are most apt 
to occur during the decline of the rash. The slight cases, constituting the 
common diarrhoea of the disease, generally begin early, whilst the grave 
cases usually date from a later period of the disease. The causes of these 
complications seem to be various exciting agents acting upon a mucous 
membrane predisposed, by the nature of the disease, to inflammatory action. 
These agents are said to be, generally, improper food, giving rise to indi- 
gestions ; and the too early use of purgative remedies, and laxatives. In 
the cases observed by ourselves it was impossible to detect the causes. 

The symptoms are more or less abundant diarrhoea, and in some, but not 
all the cases, sensibility with tumidity and tension of the abdomen. This 
complication does not exert much influence upon the measles, which usu- 
ally pursue their regular course. Sometimes, however, it occasions an 
aggravation of the febrile symptoms, and, when of a grave character, may 
no doubt interfere with the regular progress of the eruptive disease. 

According tc Killiet and Barthez, this complication was very seldom the 
only, or even chief cause of a fatal termination. Scarcely five or six of 
all that they observed could be considered as of that kind. It increases 
very much, however, the danger of the pulmonic attacks, for the latter are 
much less serious, so long as they exist alone, while so soon as intestinal 
inflammation is added to them, they become almost necessarily fatal. The 
seven cases that we met with recovered under simple treatment. 

In a considerable number of cases, a slight diarrhoea, to which we have 
already referred as a common event in measles, occurred, but only in the 
seven above mentioned did it amount to a serious complication. 

In one case that came under our observation, in a girl between five and 
six years old, fatal cerebral symptoms, due either to congestion of the brain 
or uraemia, occurred just as the rash was disappearing. There was no evi- 
dent cause whatever for this accident. There had been no imprudence 
either as to diet or exposure. The child was, however, of a tubercular 



I 



CASE. 777 

fjimily, the mother having at this very time tubercular diseavse of the lungs. 
The eruption had come out well and properly, and continued to do so on 
the second day without any irregular or threatening symptoms. On the 
third day of the eruption this began to decline, and the child had an at- 
tack of spontaneous vomiting, but continued through the day cheerful and 
pleasant. The night of that day she was restless and feverish, and wanted 
much drink. On the fourth day she was drowsy and heavy, and com- 
plained of her head. We saw her first in the evening of this day. She 
was then very dull and heavy, scarcely answering questions, and protrud- 
ing the tongue slowly and after much urging. She had some little, but 
not a troublesome cough. Careful examination revealed no disease of the 
thoracic organs. The respiration was natural, and the pulse full and very 
frequent. On the morning of the fifth day the patient was comatose, 
neither answering questions nor protruding her tongue. In the course of 
the day there were some irregular convulsive movements. In the evening 
the right arm was rigidly flexed at the ell)ow, and the left one stiftty ex- 
tended. The patient died that night. No autopsy could be obtained. 

In another case death occurred from sudden effusion of serum into the 
internal cavities, caused apparently by the existence of an excessively 
hydra^uic state of the blood, possibly connected with albuminuria, which 
had been allowed to come on gradually, without any attempt on the part 
of the parents to seek a remedy during the slow approach of this condition 
of the circulating fluid. 

Case. — The patient was a boy in the second year of his age, who had a phthis- 
ical mother. The attack of measles took place in the last week of January, 1852, 
and was regular, and not, according to the account of the parent?, we not having 
seen the child, at all severe or dangerous in any respect. After the attack was over, 
however, and though he was running about the house as before, he continued to look 
more and more pale and sickly until the evening of February 25th, when suddenly 
after 11 p.m., he was seized with fever, and becjune very restless. On the following 
day, at 9 a.m., we .^aw him. He was then extremely pallid, and very drowsy and 
heavy ; the breathing was rapid and oppressed, the pulse very frequent, and the skin 
hot and dry. He was evidently dropsical, as both the face and hands, and the feet 
also, were puffed, smooth, and doughy. The bowels had not been opened the previous 
night. In the evening the pulse was 170 ; the skin was still hot, and the breathing 
very rapid and much oppressed. There was scarcely any cough. The percussion 
was dull over too large a space in the pra-cordial region; the cardiac impulse was 
obscure, and the sounds indistinct and muffled; there was no bellows-murmur. 
The percussion was dull over the inferior dorsal regions. No rale what<«ver was 
heard. The child died on the following morning at 3J o'cloc-k. Ten minutes be- 
fore his death he asked for a drink, lifted himself up in bed, drank freely, looked 
around intelligently, and then laid down and died. At the aut<»psy the subcutane- 
ous cellular tissue was found to be infiltrated with serum. On puncturing the right 
pleural sac, there was an immediate escape of a clear, straw-yellow serum. There 
was considerable effusion in the left pleura also, but lees than in the right. The 
pericardium contained at least two ounces of serum, so that it was pushed off to a 
considerable extent from the heart. There was a slight pleuritic adhesion of the 
upper lobe of the right lung to the ribn. This was, however, evidently of an 
ancient date. There was no other inflammation of the pleura?, and none of the 
peric.irdium. Both lung* contained tubercles, which were not very niimerou'*, but 
in the upper lobes of considerable size. There was no pneumonia, but both lungs 



778 MEASLES. 

were somewhat congested. The heart was larger than usual. In the right auricle ■ i 
there was a rather large, and white, but soft concretion, and a smaller one in the ■ ■ 
right ventricle. The left cavities presented no concretions. The valves were 
healthy. 

There are several other disorders which sometimes complicate or follow 
measles, but as we have already given as much space to this subject as the 
limits of the work will allow, we shall be satisfied with a simple enumera- 
tion of them. They are otitis, ophthalmia, haemorrhages, gangrene of the 
cheek or vulva, anasarca, and different cerebral symptoms. AVe will merely 
add that measles appear to possess a special tendency to develop tubercular 
disease in the system, and that it is necessary, therefore, to treat a child 
showing any predisposition to that diathesis, or one born of tubercular 
parents, with particular caution, both at the time of the disease and dur- 
ing the convalescence. It is not uncommon for measles to be conjoined 
with other eruptive diseases. We have known it to coexist with scarlatina 
in two instances, and Dr. G. B. Wood has met with a fatal case of the 
same nature. It may be associated likewise with variola or with ery- 
sipelas ; of the latter we have met with one instance. We will mention 
here that of the whole 314 cases of measles that we have observed, 257 
were simple and 57 complicated. The complications were as follows: 
bronchitis, 24; pneumonia, 6 ; laryngitis, slight or severe, 8 ; dysentery, 7 ; 
pertussis, 7 ; scarlatina, 2 ; convulsions in the early stage of the disease, 5, 
and in the latter stage, 3 ; keratitis, 2 ; intermittent fever, 1 ; erysipelas, 
1 ; meningitis, 1 ; congestion of the brain, 1 ; serous efl^usion into the in- 
ternal cavities, 1. It ought to be observed, however, that in the above 
enumeration several cases are referred to twice, and one, a case in which 
pertussis, bronchitis, and convulsions occurred, three times. 

Anatomical Lesions. — It is difficult to ascertain what are the char- 
acteristic lesions of measles, because of the fact that most of the fatal 
cases prove so in consequence of some complication. Some few fatal 
cases, however, of the regular form, and some in which the complication 
was so slight as not to be likely to change the morbid appearances much, 
have led to the following conclusions. 

The lesions present in measles are the following : general congestion of 
different organs, which are colored red from the imbibition of blood and 
sometimes softened. The congestion affects the mucous membranes par- 
ticularly, and imparts to them a reddish or slightly blackish color. In 
some of the cases there is morbid development of the intestinal follicles. 
The most important lesion, however, is that of the blood, which presents 
the appearances common to the class of pyrexiae. These are normal pro- 
portion or diminution of the fibrinous, with increase of the globular ele- 
ment of the blood. Dr. Copland {Diet. Prac. Med., vol. ii, p. 819) gives 
the appearances in a few fatal cases of malignant measles. They were, 
softening of the tissues and the facility with which they were torn ; the 
presence, in some of the cases, of a turbid or sanguineous serous fluid in 
the serous cavities ; general congestion of the lungs ; dark appearance, 
and livid or purple ecchymoses of the bronchial mucous surface, of the 



DIAGNOSIS. 779 

fauces, stomach, and ciecum ; engorgement with dark and semifluid blood 
of the veins and sinuses of the brain, and of the auricles and lar<re veins; 
and tinally a livid and mottled appearance of some parts of the body, with 
petechiie of a dark color. 

Diagnosis. — It is impossible to diagnosticate measles in the first stage 
with any considerable certainty. The existence of the disease may be 
suspected in that period from the appearance of the eyes, from the coryza 
and sneezing, the frequent, hoarse, scraping cough, and the fever, head- 
ache, and thirst. If, in connection with these symptoms, it happens that 
an epidemic of measles be prevailing at the time, or that the child has been 
exix)sed to the contagion of the disease, the inference becomes still more 
plausible. Nevertheless, any opinion upon this point ought to be given 
with much reservaticm. 

We have already alluded to the opinion of some authorities, that the 
diagnosis in the early stage is aided by the presence of punctated redness 
of the roof of the mouth, or of a red papule on the velum palati. 

After the eruption has come out fully, it is not likely to be mistaken for 
any other disease, unless it be roseola or rotheln, the rash of which some- 
times resembles that of measles very closely. It may be distinguished, 
however, by attention to the concomitant symptoms, by the slight degree 
of fever, the more rapid evolution of the rash, and the absence of the pe- 
culiar catarrhal symptoms in roseola. In the very early stage of the erup- 
tion, measles may be confounded with variola. A careful attention, how- 
ever, to the size and shape of the papules, which in measles are much 
larger, flatter, less elevated, softer, and without the shotty feel peculiar to 
the papules in variola, and the presence of the catarrhal symptoms, will 
usually sufl5ce to distingui>h them, even in the earliest stage. In measles 
also the general symptoms persist, or even become aggravated after the 
appearance of the eruption, instead of abruptly subsiding as they do in 
variola. A little later, the appearance of vesicles pn some of the papules 
about the face in variola, will show the difl^erence still more strongly. The 
distinction between measles and scarlatina has already been drawn in the 
description of the latter disease. It rests chiefly on the much shorter du- 
ration of the prodromic stage, the greater violence of the anginose symp- 
toms, the absence of the peculiar catarrhal symptoms, and the more 
rapid evolution of the eruption in .scarlet fever; and lastly, on the dif- 
ferences in the two eruptions, observable especially at their first appear- 
ance. 

The eruption of typhus fever appears nearly at the same time as that of 
measles, and in their earliest stage the two eruptions often resemble each 
other closely. In typhus, however, there is an entire absence of the char- 
acteristic catarrhal symptoms. The spots are less elevated; are isolated 
and round, instead of coalescing to form cre.«centic patches ; do not ap|)ear 
first on the face, but on the trunk or wrists (Ringer; ; more frequently be- 
come petechial, and la.st a much longer time. 

When measles are conjoined with some other eruption, the diagnosis is 
to be made out by a careful study of the initial .symptoms, and of the 
eruption on diflTereot parts of the body, for we can generally find well- 



780 MEASLES. 

marked patches of the rash peculiar to each on some portions of the sur- 
face. In one of the cases of measles and scarlatina that we saw, the latter 
disease was developed first. The eruption made its appearance in the usual 
form ; on the second day of the eruption, the child was seized with hard, 
hoarse, laryngeal cough, and with redness of the eyes and lachrymation. 
These symptoms continued three days, at the end of which time the scar- 
latinous rash had disappeared from the face, but remained visible upon 
the trunk and extremities. Characteristic measly papules now made th^ir 
appearance on the face, and pursued their regular course, while on the 
trunk and extremities the measly eruption was never well defined, being 
mixed with and disguised, as it were, by that of the scarlatina. In the 
other case, the measles appeared first and went on regularly until the 
eruption was declining and the general symptoms moderating, when 
suddenly the fever, heat of skin, restlessness, and irritability returned, 
and the child was very soon covered with the punctated scarlet rash of 
scarlatina. 

Prognosis. — The prognosis of simple, uncomplicated measles is very 
favorable ; the cases almost always recover without difiSculty. This is 
shown to be true by the following facts : Rilliet and Barthez report 36 
cases of simple measles, of which all but one recovered. Of 257 cases 
that we have seen, all terminated favorably. When, on the contrary, 
complications occui', the disease always becomes more or less dangerous, 
the degree of danger depending on the nature of the intercurrent afiection, 
and on the hygienic conditions in which the patient is placed. Thus of 
131 cases observed by the above authors, in which some form of complica- 
tion occurred, 89 or about two-thirds proved fatal, while of the 53 com- 
plicated cases that we have seen, only 6 were fatal. It must be recollected 
that the cases of the French observers all occurred under the unfavorable 
hygienic conditions of a large hospital, in children of bad constitution from 
congenital or acqired causes, whilst ours were observed in private practice, 
where the hygienic conditions are favorable in the same degree as they are 
unfavorable in hospitals. 

The six fatal cases that came under our observation, proved so from the 
circumstances we are about to mention. The first occurred in a child Jiine 
months old, who was laboring under pertussis when attacked with measles. 
Bronchitis supervened upon the measles, and proved fatal by convulsions, 
which came on during a paroxysm of hooping-cough, two weeks after the 
disappearance of the rubeola. The second case was that of a boy, eighteen 
months old, who was prescribed for by an apothecary from behind his coun- 
ter, until we saw him. The eruption made its appearance imperfectly, we 
were told, and with a convulsion. After this he was very restless, and had 
rapid and difficult respiration and much cough. On the morning of the 
fourth day of the eruption, this had almost entirely disappeared, and the 
child was again attacked with convulsions. We saw him shortly after 
this for the first time, and found him comatose, with convulsive move- 
ments of the limbs, extreme dyspnoea, and all the symptoms of extensive 
bronchitis of both lungs. He died thirty-six hours from this, as was to be 
expected. The third was a case of pneumonia in a child between, one and 



TREATMENT. 781 

two years of age, iu which the inflammation came on as the eruption was 
fading, and proved fatal, in spite of all that could be done, on the eleventh 
day. The fourth occurred in a boy between four and five years old, who 
appeared to recover perfectly from the measles, but was attacked in ten 
days with meningitis, and died. The fifth was the case of congestion of 
the brain, already detailed in the remarks upon complications, as proving 
fatal shortly after the decline of the rash. The sixth was that of sudden 
dropsical etiusion into the internal cavities, also described in the remarks 
upon complications. 

To conclude, we may state that the prognosis is always highly favorable 
under the folh)wing circumstances: when the disease is primary; when 
the initial stage is of the proper duration ; when the eruption begins upon 
the face and extends gradually to the rest of the bod}"^ ; when the febrile 
movement is moderate ; when the eruption, after increasing for one, two, 
or three days, gradually decreases; when the cough and other concomitant 
symptoms diminish with the fever; when the cutaneous surface, after the 
fading of the rash, assumes a natural color, and is neither flushed nor 
pale ; when the appetite returns, the disposition to be amused and take 
notice continues, and lastly when the sleep is natural. 

On the contrary, the prognosis becomes unfavorable under the following 
circumstances : when the initial stage lasts longer than usual, and when 
it is accompanied by violent symptoms of any kind, as extreme jactita- 
tion, irritability, dyspna\i, much stupor, coma, or convulsions; when the 
eruption is irregular in its appearance or course; when the fever does not 
disappear with the eruption, whether it remains violent or assume the 
form of hectic; when, after the eruption, the face continues deej)ly flushed 
or becomes very pale ; when the cough, dyspntiea, or diarrlura persist; 
and, lastly, when the child remains weak, languid, dispirited, or irritable. 

It may be stated, iu conclusion, that the prognosis of measles is always 
favorable in proportion to the health of the child at the time of the inva- 
sion, and the regularity with which the disease passes through its different 
phases; while it becomes unfavorable, though far less so in private prac- 
tice amongst people in easy circumstances, than in hospitals or amongst 
the poor and wretched, whenever it attacks a child already laboring under 
some disease, and when it becomes complicated with any other malady, 
either local or general. 

Treatment of the Regular, Simple Form. — This form requires, in 
a large majority of the ca»es, little other treatment than strict attention 
to the hygienic condition of the patient, the use of simple diaphoretics, of 
mild cathartics occasionally, and the palliation of any of the sym]H()m8 
that may chance to become somewhat more troublesome than usual. 

The child ought to be confined as much as possible to bed in a large, 
well-ventilated chamber, the light in which should be somewhat softened. 
Every precaution should be observed to prevent chilling of the body, 
while at the same time it is nearly, if not quite as important, to avoid 
overheating the patient, either by excessive clothing, or by keeping the 
temf)erature of the rfK)ra too high. In winter, it is well to direct the 
temperature to be maintained at between 68'^ and 70^ F., night and day. 



782 MEASLES. 

If this be done, the child is not apt to take cold, even though it be un- 
covered at times, and yet the warmth is not oppressive. We have often 
remarked that this temperature is just what it ought to be when the room 
is well ventilated, either by means of an open fireplace, or by communi- 
cation with adjoining rooms; but when, on the contrary, the room is 
heated by a furnace-flue, and not ventilated at all, or very imperfectly, 
the same temperature, as indicated by the thermometer, becomes ex- 
tremely close and oppressive. Under such circumstances, a door into an 
adjoining room, or if this cannot be, one into the entry, ought to be kept 
more or less open, with a screen of some kind between it and the child, in 
order to secure a good ventilation, which is assuredly of the very highest 
importance, and yet to prevent by the screen a current of cool air from 
chilling the patient. Miss Florence Nightingale remarks that doors 
are made to be shut and windows to open.- There is much in this saying, 
and when the nurse is intelligent and observant, we much prefer to shut 
the door and open a window. In our winter temperatures in this city 
this must be done very carefully. One of the sashes raised an inch, or 
one or two inches, will make a large difference in the temperature and 
vitality of the air of the sick-room. 

The diet during the febrile period ought to be very light. It may con- 
sist of milk and water, of arrowroot, sago, or tapioca, prepared with milk 
or water; or of crackers soaked in water, with salt, or some similar food. 
When the eruption and fever have in great measure disappeared, some 
light broth, either vegetable or animal, with dry toast or bread, plain 
boiled rice, a roasted potato, or ice cream, may be added ; and after all 
the symptoms have ceased, the usual diet can be gradually resumed. The 
drinks may consist of simple water, of lemonade, orangeade, gum-water, 
or flaxseed tea, with the addition of a little sweet nitre ; or of weak infu- 
sions of balm, sweet marjoram, or saffron, or cascarilla with a few drops 
of hydrochloric or nitric acids. They may be given in any reasonable 
quantity, at the temperature of the room. Some persons have a great 
dread of cold water in this disease. We have never seen small quantities 
(a wineglassful or two at a time) of cold water do any harm, and believe 
it to be most useful and necessary when the fever is violent, and the heat 
very great. We once, however, saw a boy, nine years old, attacked with 
violent colic and partial retrocession of the eruption, after swallowing 
suddenly a tumblerful of iced water. The unpleasant symptoms passed 
off in a few hours, and he had no difficulty afterwards. 

The patient should not be permitted to leave the room until a few days 
after the entire disappearance of the disease. This precaution is necessary 
for all, but particularly for the delicate, and in the cold weather of these 
latitudes. He should be kept in the house until he has regained in some 
degree his usual health, and then sent out with due precautions. 

Medical Treatment. — Many cases of measles — the mild, the moderate, 
the uncomplicated — need no other treatment than that just laid down in 
the paragraph on the hygiene of the disease. So long as the case goes on 
regularly, so long as the symptoms are moderate and such as to cause but 
little suffering, there is no necessity for drugs, or, at the most, a simple 



TREATMENT. 783 

diaphoretic, as sweet spirit of nitre or the solution of acetate of ammonia, 
with a little paregoric or laudanum once or twice in the evening, will be 
all that ought to be done. 

The child doe^s not require, and therefore ought not be made to take as 
a mere routine, cathartics. If the bowels are known to be costive, and not 
to have been moved ft.r two or three days, a teaspoonful or dessert^^poonful 
of castor oil, or, better still, a dessertspoonful to a tablespoonful of simple 
syrup of rhubarb, or a simple enema, will answer every purpose. We are 
sure that active purging is unnecessary, and apt to be hurtful. 

When the case is a very decided one, and the eruption extensive and 
deep in color, the fever runs high, and the patient often sutlers greatly 
from the fever-pains, and from the violence and frequency of the cough. 
Here medical treatment is necessary, since it lessens sutleriug, diminishes 
the violence of some of the symptoms, and so promotes the safety of the 
patient. In infants, under these conditions, we order five drops of sweet 
spirit of nitre, two or three of syrup of ipecacuanha, and two of paregoric, 
in a teaspoonful of sweetened water every two hours, at the age of six 
months. At one and two years, we double the proportions of the active 
ingredients. Should even these small doses of ipecacuanha cause any 
sickness of stomach, we lay that drug aside. One of the best combina- 
tions is the following : 

E.— Potass. Citrat , ^}. 

Spts. Ether. Nit., f^ij. 

Tr. Opii Deodorat., . . . . . . "X^'j ^^1 xriv. 

Syrup. Simp., f.o^j- 

Aquae, . . , ... . . f5ij. — M. 

D'1'0. — A tablcjpoonful every two or three hours, at five years of age. 

In younger children, from two to five years, the same formula may be 
used, except that the laudanum should be reduced to six minims. When 
the cough is very dry, scraping, and, as it sometimes is, incc-'sant, there 
should be added to the above mixture syrup of ipecacuanha, in the pro- 
portion of five to ten drops to every teaspoonful, according to the age of 
the child ; and there may and ought to be given from time to time, if the 
patient be not too drow.^y from the effects of the fever or the mixture, an 
extra dose of opium. We prefer nearly alway.s the deodorized laudanum. 
Of this from two to four drops in a teaspoonful of water may be given two 
or three times a day, or, better still, once or twice in the evening, to chil- 
dren over five years of age. From one to five years of age, one or two 
drops are enough. In some few children paregoric may an.«wer better, 
but this rarely happens. When it is given, ten to twenty drops at five 
years, five or ten at one year, and from half a teaspoonful to a teaspoonful 
over five years, may be u.sed instead of the laudanum. 

Depletion, except that which comes of the above treatment, if< unnec- 
essary. We did, in past years, use depletion in 2 ca,ses out of 2.">7 regular 
cases of which we kept notes. In one, a venesection to four ounces was 
used in a boy seven years old, on account of the great violence of the 
febrile movement ; and in the second, leeches were applied to the temples 



784 MEASLES. 

for an intense headache in a girl nine years old. For many years past 
we have used no general bleeding, but might be tempted to use leeches in 
a case of the same kind as that just mentioned, in which the pain in the 
head was something quite out of the usual way. Instead of venesection 
we should make use of a warm bath continued for fifteen to twenty min- 
utes. If the temperature of the body be very high, it may be reduced by 
careful sponging with tepid or cool water. 

Sometimes, when the cough is very troublesome, a mustard foot-bath 
used every three or four hours, and a mild liniment, as one composed of 
sweet oil and spirit of hartshorn, or of chloroform, camphor, and soap 
liniment, rubbed gently upon the front of the neck and over the upper 
part of the sternum, will assist materially in palliating this symptom. 

When the conjunctival inflammation is acute and painful, it may be re- 
lieved by lotions with simple warm water, milk and water, or sassafras- 
pith mucilage, alone or mixed with rose-water. If the headache be very 
violent it can generally be relieved by the use of a laxative, by the occa- 
sional use of a mustard foot-bath, or of a sinapism to the nucha, and by 
the application of cold to the head. 

If, at any time during the course of the case, symptoms of exhaustion 
appear, the most nourishing and concentrated food, with alcoholic stimu- 
lants in graduated doses, should be promptly resorted to. 

The malignant form of the disease must be treated chiefly with stimu- 
lants and tonics. The most useful are wine and brandy, quinia, ammonia, 
capsicum, etc. Camphor and opium would be proper, were the case at- 
tended with severe nervous symptoms. The diet ought to be nutritious 
and digestible, and may consist of milk and bread, light broths, and beef 
tea or essence of beef. 

When local inflammations occur, they may be treated by a few dry cups, 
or by means of counter-irritants, of which the most suitable are mustard, 
spirit of turpentine, or ammonia. Blisters ought to be avoided, as they 
are very apt to occasion dangerous and even fatal sloughing. 

Treatment of the Complications. — Bronchitis, Pneumonia. — The 
mode of treatment of these complications must depend upon the stage at 
which they are developed, and upon the age and constitution of the sub- 
ject. When they occur during the first stage, one of the most important 
points in the treatment is to endeavor to favor the appearance of the erup- 
tion, and when in the second stage, and the eruption has retroceded wholly 
or in part, the same indication applies with equal force. When they ap- 
pear during the third stage, they are to be treated without any regard to 
the eruption, but always with reference to the fact that the patient has 
just passed through an acute febrile disease, which must have weakened 
in some degree the vital powers. 

It may be stated in general terms, that the treatment proper for these 
local inflammations when they occur as i)rimary affections, is proper also, 
with some reservations, under the circumstances we are now considering. 

Thus even local depletion should be employed only with the greatest 
care, and, indeed, we should recommend in preference the application of 
dry cups, or of sinapisms. 



TREATMENT. 785 

Purgatives should also be used with caution, on account of tlio dispo- 
sition to gastro-intestinal irritation which is always })resent in this dis- 
ease. Our own practice is to oniplov moderate counter-irritation, in con- 
junction with minute doses of sulphuretted antimony a»id Dover's powder, 
or a mixture containing citrate of potash and syrup of ipecacuanha. 
When in these cases the skin is at all coolish, or bathed with too consid- 
erable a perspiration, we have found the liquor ammonia^ acetatis a very 
useful remedy. 

It is universally acknowledged that it is exceedingly important to assist 
nature in throwing out the rash, whenever these complications either pre- 
vent its formation, or cause its; retrocession. The true mode of doing this 
is to cure or alleviate the internal inflammation, which is the cause of the 
difficulty. To attain this end the above plan of treatment ought to be in- 
stituted at once. At the same time, we may greatly assist the appearance 
of the eruption by a persevering employment of counter-irritants. The 
best of these is, we believe, mustard, and in some cases a warm bath. The 
mustard may be used in the form of plasters, poultices, or baths. Our 
own plan in moderately severe cases, is to apply a mustard poultice to the 
interscapular space, and to make use of a mustard foot-bath, two or three 
times a day, while in severe and urgent attacks we direct the cataj^lasm 
and bath to be renewed every two or three hours, taking care, however, to 
apply the former alternately to the front and back of the chest, in order 
to avoid all possibility of too violent an action upon the skin ; the feet 
and lindis also ought to be carefully watched, to avoid the same danger. 
We have had occasion to observe the great efficacy of this unremitting 
employment of revulsives, in several severe cases of bronchitis in young 
children. In some we have depended solely upon this treatment, and the 
use of small doses of ipecacuanha and spiritus Mindereri. In one partic- 
ularly, which occurred in a child eight months old, the attack came on in 
the first stage. On the fourth, fifth, and sixth days, the dyspnoea was ex- 
cessive, the respiration running up to 70 and 80 ; the pulse was frecpient 
and small ; the skin pale and rather cool; and the irritability and rest- 
lessness very great. For a period of twenty-four hours, we used the poul- 
tices and foot-baths every two hours regularly, and gave internally the 
spiritus Mindereri at the same intervals. Nothing else was done. On 
the sixth day, when one of the poultices was removed from the inter- 
scapular space, the integument beneath was observed to be covered with 
the measly stigmata, whilst there were none as yet on any other part of 
the surface. From this time the eruption came out freely, and the child 
recovered rapidly. 

The warm bath may be used under the same circumstances. It should 
be given with great care, the child being wrapped in a warm blanket the 
moment it is removefl from the water, to prevent the least sensation of 
chilliness. It may either lie for a short time in the blanket, or be wiiK'd 
dry beneath it, and then dressed. 

In 84»me of the cases of bronchitis, there has been profuse secretion at- 
tended with extensive subcrepitant and mucous rales. In such instances 

60 



786 MEASLES. 

we have found tlve internal use of the syrup or infusion of polygala seneka, 
"with an occasional revulsive, very effectual. 

The diarrhoea which occurs so frequently seldom requires any treatment. 
Indeed, unless it indicates evident entero-colitis, or is accompanied by fre- 
quent mucous or bloody stools, and by pain and tenesmus, it is better not 
to interfere with it, beyond paying strict attention to the diet. When at- 
tended, however, with the symptoms just mentioned, it must be treated by 
astringents, by opium and ipecacuanha, and by the application of poul- 
tices to the abdomen. The seven cases that occurred to ourselves recov- 
ered under the use of laudanum enemata, given twice or three times a day, 
the strictest diet, and small doses of Dover's powder. 

Laryngitis, as it occurs in most of the cases, needs but little treatment 
beyond careful avoidance of cold, the use of some mild nauseant, and re- 
vulsives to the neck. It is very seldom of a dangerous character. When, 
however, it assumes the character of pseudo-membranous croup, it must 
be treated with all activity, in the manner described in the article on that 
disease. In only two of the eight cases we have seen, did it appear at all 
threatening, and both of these recovered under the use of emetics and 
moderate leeching of the throat. 

The cerebral symptoms which sometimes occur, must be treated differ- 
ently in different periods of the disease. In the early stage, when they 
last but a short time and do not recur, they require nothing more than a 
warm bath and the use of revulsives. If they continue to recur, or are 
followed by stupor or other cerebral symptoms, more energetic treatment 
becomes necessary. If the child is strong and hearty we ftiay apply dry 
cups to the back of the neck or temples, and resort to purgatives, revul- 
sives, and cold applications to the head. When the symptoms are violent, 
and when the heat is intense, it has been proposed to use cold lotions in 
the manner recommended in scarlatina. The evidence upon this point is 
not very conclusive, and as we have never used them, nor seen them used, 
nor indeed seen any necessity for a resort to them, we can offer no opinion 
in regard to their value. 

We have met with five cases of convulsions in the first stage. One oc- 
curred in a boy five years old ; the convulsions were slight, lasted not more 
than ten or fifteen minutes, and were followed by no bad symptoms. The 
intelligence of the child returned very soon afterwards. The only remedy 
used was a warm bath. The other cases have already been described. 

When convulsions occur in the second or third stages, it is very impor- 
tant to ascertain whether they are not the result of some local disease. 
Two of the three cases that came under our notice accompanied violent 
attacks of bronchitis. The third was caused by congestion of the brain. 
Here the treatment must be directed against the local disease, if that can 
be detected. When, on the contrary, the convulsions seem to depend on 
nervous irritation, they may be treated with baths, revulsives, purgatives, 
and the careful administration of opium, as recommended by Sydenham, 
Copland, Rilliet and Barthez, and other authors, or of bromide of potas- 
sium, camphor, assafoetida, musk, or hyoscyamus. If accompanied by 



SMALL-POX. 787 

intense heat and great dryness of the skin, without local complications, 
cold or tepid lotions may also be tried. 

The treatment suitable when any of the complications or sequela^ become 
chronic, will be found in the articles devoted to the respective diseases. 
Bearing in mind the tendency to the development of scrofula or tubercu- 
losis after this disease, the most careful attention should be paid to all hy- 
gienic measures; and alteratives and tonics, as syr. ferri iodid., cod-liver 
oil, and quinia, should be administered. 



ARTICLE VIII. 



VARIOLA, OR SMALL-POX. 



Defixition; Frequency; Forms. — Variola is an epidemi^c and con- 
tagious disease, characterized by an initial fever, lasting from three to four 
days, and followed by an eruption at first papular, then vesicular, and 
afterwards pustular ; the eruption attains maiturity in from six to nine days, 
after which the pustules are converted by desiccation into scabs, which fall 
off between the fifteenth and twenty-fifth days. 

The freqmucy of the disease varies greatly in diffv^rent years, because of 
its epidemic nature. It is far less common in childhood amongst the mid- 
dle and upper classes of the community, than either measles or scarlatina, 
in consequence, no doubt, of the attention paid to vaccination. During 
the early months of L'^Go, one of us had the opportunity of studying a 
severe epidemic which occurred in portions of this city, and we have pub- 
lished elsewhere' an analysis of thirty cases in children under fifteen years 
of age, observed at that time. Apart from these cases, however, we had 
met with but two cases of the disease under fifteen years of age, during 
the fifteen years preceding 1871-72, whilst during the same i>eriod we had 
met with 263 of scarlatina, and upwards of 314 of measles. In the last- 
mentiouefl years, a severe epidemic occurred in this city, when we again 
saw numerous cases at all ages. It prevails to a greater extent amongst 
the p<K)r and destitute classes, who neglect the attention to vaccination 
necessary to preserve children from the disease. 

We abstract from the article already referred to, the following table, 
showing the entire annual mortality from variola in Philadelphia, together 
with the relative mortality during the early years of life, for the twenty- 
four years ending 1873. 

> Amer. Jour, of Med. 8ci., October. 18G9, p. 322. 



788 



SMALL-POX. 



MORTALITY FROM VARIOLA. 



1848, 
1849, 
1850, 
1851, 
1852, 
1853, 
1854, 
1855, 
1856, 
1857, 
1858, 
1859, 
1860, 
1861, 
1862, 
1863, 
1864, 
1865, 
1866, 
1867, 
1868, 
1869, 
1870, 
1871, 
1872, 



Tot 



Under 


Between 1 


Between 2 


Total of all 


1 year. 


and 2 years. 


and 5 years. 


ages. 


21 


13 


17 


100 


25 


20 


34 


152 


13 


8 


4 


40 


40 


30 


54 


216 


89 


54 


100 


427 


22 


9 


9 


57 


12 


4 


6 


49 


57 


39 


85 


275 


86 


44 


88 


390 


19 


17 


11 


65 


1 


2 


1 


7 


0, 





1 


2 


14 


10 


16 


57 


159 


105 


200 


758 


52 


44 


66 


264 


33 


24 


28 


171 


57 


31 


61 


260 


104 


50 


112 


5J4 


32 


17 


27 


144 


16 


4 


11 


48 











1 


1 


3 





6 


3 





3 


9 


203 


112 


292 


1879 


347 


188 


446 


2585 



1406 



828 



1672 



8486 



An inspection of this undoubtedly establishes the fact that whenever the 
contagious principle of variola, favored by some peculiar epidemic influ- 
ence, is introduced into this community, it finds a large number of unpro- 
tected subjects who fall ready victims to its attack. 

We shall, in our description of variola, refer to several forms which it 
may assume. These are merely degrees of severity of the same disease — 
types given to each case by several causes. Chief amongst these is the 
presence or absence in the person attacked, of the protective power of the 
vaccine disease, next is the type of the epidemic prevailing at the time, 
and last we must place the inexplicable and utterly uncertain influence of 
individual constitution. According to the degree of reaction of the vari- 
olous poison in the system of the patient, shall we have distinct or discrete, 
confluent or hmmorrhagic small-pox ; or that form modified by vaccination, 
inoculation, or previous natural small-pox, called varioloid. 

We shall also describe the complications of the disease. 

Causes. — The principal causes of variola are contagion and epidemic 
influence. 

It is not clearly ascertained at what period of its course the disease first 
acquires the property of infectiousness. Some assert that it is not until 
after suppuration is established. This is, however, to say the least, doubt- 
ful, and it is best, therefore, to take any precaution that may be necessary 



SYMPTOMS — COURSE — DURATION. 789 

to prevent the extension of the disease, from tho inoinont that its roal nature 
beeomes apparent. There can be no doubt that the body niay still impart 
the disease after death, and that clothes worn bv the patient retain the 
contagious principle, unless freely exposed to the air, for days, months, 
and, it is said, even for veal's. It is also capable of infecting furniture or 
letters, and may thus propagate the disease at any distance, and for an 
indefinite periinl, l)y fomites. 

One attack protects the constitution, in the great majority of cases, 
against subsequent contagion. When persons who have once had the dis- 
ease contract it again, it almost always assumes a much milder and less 
dangerous form. 

In the report of the Municipal Hospital of Philadelphia, made to the 
Board of Health of Philadelphia, for the year 1872, Dr. Wm. M. Welch, 
the physician in charge, states that out of the whole number of cases 
(2377) of variola admitted during the violent epidemic of 1871-2, 15 were 
said to have had a previous attack of the disease. Of these 15 cases, those 
which could not show a single scar as the result, he should classify as of 
doubtful authenticity ; those which exhibited only a few scars, as of prob- 
able authenticity; and those which exhibited well-marked pitting as au- 
thentic. To the first class belonged 7 cases, of which 3 died ; to the second 
class belonged 3 cases, all of which recovered ; to the third class belonged 
5 cases, all of which recovered, and in all of which the eruption was very 
light, so much so in one as to be characterized as doubtful. 

The period of incubation, or the time elapsing between the reception of 
the poison and the onset of the malady, varies generally between nine and 
twelve days. It may, however, be seven or fifteen days. 

Symptoms; Course; Duration. — We shall describe three stages of 
the disease: 1. That of the initial or eruptive fever; 2. That of the prog- 
ress and maturation of the eruption ; and, 3. That of decline or desiccation. 
In addition to these, some writers make another stage, that of incubation, 
which includes the period between the introduction of the poison into the 
system, and the appearance of the first symptoms. This stage is seldom 
marked by symptoms sufficiently characteristic to enable us to detect the 
approaching disease, and in many instances is probably entirely unnoticed 
by the patient. 

TUe first dage, or that of initial fever, commences generally in children 
with pains in the bones and loins, and sometimes with rigors or chilliness, 
accompanied with headache, and soon followed by fever. Nausea and 
vomiting often exist from the first, or come on soon after the appearance 
of fever and headache. At the same time there is loss of appetite, thirst, 
and more or less obstinate constipation. The tongue is red at the point 
and edges. One of the characteristic sy«nptoms of this stage is pain in 
the loins, which generally dates from the first or secon«l day, and which, 
though varying much in degree, is usually severe. Tho patients often com- 
plain also of abdominal pains, which seem to be colicky, and are referred 
either to the epigastric or umbilical region. 

Fever and headache are the most con?*tant f)f all the initial symptoms. 
The chilliness and rigors which frequently exist in adults are not easily 



790 



SMALL-POX. 



ascertained in the cases of children, and are therefore much less important. 
The fever varies greatly as to degree ; the heat of skin is generally con- 
siderable, the temperature rising to 104° or 105°, and may be accompanied 
either with dryness or moisture. The pulse is commonly full and frequent, 
rising to 120, 140, or 160 beats, according to the severity of the case and 
the age of the child. The headache is usually frontal and often very 
severe. In some cases there are strongly marked cerebral symptoms, con- 
sisting of excessive restlessness and irritability, insomnia or somnolence, 
delirium, and even convulsions. 

The various symptoms just enumerated continue up to the moment when 
the eruption begins to make its appearance, which happens generally in 
the course of the third day, though it may occur as early as the second, or 
as late as the fifth, sixth, or even seventh. In severe and confluent attacks, 
t'.ie eruption, as a general rule, begins earlier than in mild and discrete 
cases. 

Second Stage, or that of Eruption. — In the great majority of cases, the 
specific eruption makes its appearance in the course of the third day from 
the beginning of the fever. This is the law of the disease. Before, how- 
ever, describing it, we must state that not rarely a more or less extensive 
roseolous rash precedes the specific eruption. So well known is this that 
it has been called roseola variolosa. It looks so like measles as to make 
a correct diagnosis difficult, since nothing could reveal its true character 
unless it were known that the subject had been exposed to variolous infec- 
tion, in which event the unusual severity of the constitutional phenomena, 
compared with those generally attendant upon roseola, might well lead the 
practitioner to defer his opinion. This roseola occurs in all forms of small- 
pox. Dr. Welch thinks he has seen it most frequently and in greatest 
quantity in cases of mild varioloid. 

The specific eruption appears, then, on the third day, in the form of 
small, isolated, and rounded red specks, which soon become projecting and 
solid, or in other words are converted into papules. The papules are from 
a third to two-thirds of a line in diameter, of a more or less vivid red 
color, which disappears under pressure, to return immediately when the 
pressure is removed. They are also hard, and feel almost like shot im- 
bedded in the derm. The eruption shows itself first on the face, and gen- 
erally about the chin and mouth, and then extends to the rest of the face, 
to the neck, trunk, limbs, feet, and hands. It sometimes happens, par- 
ticularly in very young children, that the eruption appears first about the 
genital organs, whilst in other cases it is first observed on the lower part 
of the loins, or upon the thighs. The papules increase gradually in size 
and prominence for one, two, or three days, and, as a general rule, some 
time in the course of the second day of the eruption, begin to change into 
vesicles. This change takes place by the formation on the top of each 
papule of a little transparent elevation of the cuticle, beneath which is 
deposited a drop of serosity. The conversion of the papules into vesicles 
occurs first on the face, and then on the neck, trunk, and extremities. The 
vesicles are at first smaller than the papules, and acuminated in shape, 
but as they grow larger, become gradually flattened and depressed in the 



SYMPTOMS. 791 

ceutre : after a time thov cover the Avhole papule, and before long exceed 
it iu size. As tliese changes take place, the fiuid they contain loses its 
trausjiarency, becomes opaline, and by degrees the vesicles are transformed 
into pustules, and thus the third stage of the eruption or that of suppura- 
tion begins. • 

The pocks are more or less numerous, according to the extent and 
severity of the eruption. When scattered over the surface so as not to touch 
at their edges, the disease is said to be distinct or discrete; when, on the 
contrary, so numerous as to come into contact and run together, it is called 
conHurnf. Of these two varieties, the latter is necessarily more severe and 
dangerous than the former, in consequence of the greater extent of tegu- 
mentary surface inflamed. During the various changes the vesicles un- 
dergo, they are surrounded by small, inflamed areolie, which differ in 
appearance according to the number of the vesicles. In cases of the 
discrete form, in which the eruption is sparse, so that the pocks are widely 
separated, the areoke fade gradually into the natural color of the skin, at 
the distance of a third or two-thirds of a line or more from the base of the 
vesicles, whilst in those in which the eruption is more abundant, they run 
together, so that the spaces between the pocks are of a more or less bright- 
red c«tlor. In confluent attacks again, the areolae are more or less imper- 
fect, according to the manner in which the vesicles are grouped together. 

The change of the vesicles into pustules take^ place generally from 
the fourth to the sixth day of the eruption. During this process the fluid 
of the pocks becomes more and more opaque, whitish, and at length 
assumes a yellowish color, being in fact converted from serum into pus. 
At the same time the pocks become larger, begin to distend, and, as they 
approach complete maturation, gradually lose their umbilicated shape and 
become convex on the surface. The formation of the pustules follows the 
same course as did the vesicles, beginning on the face and extending 
thence to the neck, trunk, and extremities. The areolie that have just 
been described as existing during the vesicular stage of the disease, con- 
tinue during the early part of the stage of pustulation, but decline to- 
wards its termination, assuming as they disappear a purple tint. The 
number of pustules is in proportion, of course, to that of the vesicles, but 
from the increase in size of the pocks during the changes from papules 
into vesicles and pustules, the eruption, when at its height, seems to be 
greatly more extensive than would have seemed probable at the beginning 
of the first stage. As a general rule the pocks are most numerous on the 
face, and after that part on the neck and limbs. On the trunk the erup- 
tion is alway?* much lei<s abundant than on other parts of the b(Kly, and 
even when confluent in the highest degree on the face and neck, it is gen- 
erally so only in patches on the limbs, while it is discrete on the thorax 
and abdomen. 

iSimullaneously with the eruption upon the skin, there occurs one also 
upon the mucous raerabranes, particularly those of the mouth, nasal 
passages, fauces, eyelid.s, and sometimes of the prepuce and vulva. It 
l>egins with more or less vivid redness of the membrane, which is followed 
by the production of little elevations, the real nature of which, whether 



792 SMALL-POX. 

papular or vesicular, seems not to be clearly determined. About the 
second or third day these red elevations assume the appearance of small, 
■sUiitish, rounded, and umbilicated pseudo-membranous points, which last 
generally about five days, and are then detached, leaving usually a little 
ulceration or erosion, which heals without leaving a cicatrix. 

A short time after the appearance of the pustules in the mouth and 
throat, a true inflammation of the mucous membrane of those parts takes 
place. When the gums are inflamed they become swelled, red, and 
spongy, and are dotted over with white pseudo-membranous points of a 
rounded shape. Sometimes the velum pendulum, and more rarely the 
tongue, present the same white points, with redness and injection of the 
membrane between. In most of the cases there is also partial or general 
inflammation of the pharynx, which occurs subsequently to the formation 
of the variolous pustules. The existence of this inflammation is denoted 
by more or less severe sore throat, attended with difficulty of swallowing, 
and with swelling and tenderness of the submaxillary glands. When the 
mucous eruption extends to the larynx, as often happens, there is pain in 
that part ; the voice becomes hoarse or whispering, and there is a hoarse, 
laryngeal, smothered cough. The pharyngo-laryngitis just described occurs 
generally between the third and sixth days of the eruption, and ceases 
about the eighth or thirteenth. In some instances it does not exist at all 
or only to a slight extent. 

During the eruption there is more or less inflammation and swelling of 
the subcutaneous cellular tissue, the degree of which depends on the extent 
of the eruption. The skin becomes tense, red, shining, and elastic under 
the finger, and more or less hot and painful. The swelling is greatest upon 
the face, where it commences about the fourth or fifth day of the eruption, 
and goes on increasing for five or six days, occasioning much pain, stiff*- 
ness, and inconvenience to the child. The swelling diminishes when desic- 
cation begins, and ceases entirely as the latter is accomplished. 

It is important to study carefully the general symptoms of the second 
stage. The fever which existed during the initial stage sometimes con- 
tinues during the first day or two of the eruption. When, however, the 
papules are fully thrown out, the fever subsides or disappears entirely, so 
that the pulse falls from 100, 120, or 140 beats, to 100, 80, 76, or 74, and 
the heat of skin diminishes at the same time. The child remains without 
fever usually throughout the vesicular period of the eruption, that is to 
say, until the fourth, fifth, or sixth day; during which time the appetite 
sometimes returns, slepp is tranquil and quiet, and the patient is in most 
respects well and comfortable. 

About the fifth or sixth day of the eruption, at which time the matura- 
tion of the pustules is nearly completed on the face, and that process is 
commencing on the extremities, a new fever, to which the technical terra 
secondary fever is applied, makes its appearance. The pulse rises again to 
88, 100, 120, and 140, and becomes strong, hard, and full, whilst the skin 
is hot and dry. After continuing for some days the secondary fever dimin- 
ishes after the suppuration is fully established, and disappears about the 
time that desiccation is nearly completed on the face, and has commenced 



SYMPTOMS. 793 

upon the limbs. It ceases generally, therefore, about the nintli or eKvonth 
day, having lasted between four and six days. This attack of fever is evi- 
dently the consequence of the suppurative stage of the disease, or of the 
conversion of the vesicles into pustules. 

Towards the termination of the second stage, at the very height of the 
disease, when the pustules begin to break and discharge their contents, the 
patient exhales a peculiar, disagreeable, and fetid odor, which is character- 
istic of the disease. 

The third or declininc/ stage is that of the desiccation or drying of the 
pustules, and their desquamation. The desiccatii>n commences generally 
between the sixth and ninth days, and terminates between the tenth and 
•fourteenth. The formation of the crusts begins upon the face and extends 
thence to the neck and limbs. It does not reach the limbs usually until 
about two or four days after it has commenced on the face. The mode in 
which the drying of the pustules takes place is not the same in all. In 
some a dark point is formed in the centre which gradually extends and 
converts the whole pustule into a hard crust ; in others the whole surface 
dries at the same time: while in others again, the epidermis gives way and 
allows the contained fluid to escape, which then hardens into yellowish, 
irregular crusts, which become brown before they fall off. Some of the 
pustules, particularly those upon the arms and legs, do not form scabs at 
all, but shrink away from the absorption of their fluid, leaving behind 
nothing but pellicles of cuticle, which fall oflT by des(juamation. 

The desquanuition or falling of the crusts begins from the eleventh to 
the sixteenth, and ends somewhere between the nineteenth, twenty-fifth, 
and even fortieth days of the eruption. When the scabs fall oflT, the ap- 
pearances presented by the skin beneath vary in diflcrent cases. In some 
a true ulceration and loss of substance of the derm has taken place, which 
gives all the characters of a suppurating ulcer when desquamation has be- 
gun early in the disease; when that process occurs at a later period, the 
ulcer is found to be dry and cicatrized. In both these forms of desquama- 
tion, the cicatrices form little pits or depressions, which remain during 
life. In other instances, the fall of the scabs leaves red and excoriated 
surfaces which are on a level with the surrounding skin, but which soon 
dry, leaving blotches of a reddish-brown color, that do not disapj^car en- 
tirely for months. No cicatrices remain when desfjuamation tak<'s place 
in this manner. In a third series of cases the crusts do not fall until the 
surface beneath has completely cicatrized, and the only traces left behind 
are more or less deeply tinted reddish spot«, with occasional slight furfu- 
raeeous exfoliation of the cuticle, all of which disappear entirely aft<r a 
time without leaving pits or cicatrices. 

To conclude the account of the s^'mptoms of the di-casc, w<' have :i tiw 
words to say in regard to the condition of some of the important organs 
throughout the course of the malady. 

The tongue presents no appearances peculiar to the disease, other than 
the eruption already described. It is generally moist, more or less furred, 
and either pale or red in color. The ahflompn tisually remains soft and 
undistended, though in some instances it is .slightly tumid and hanl, with 



794 SMALL-POX. 

occasional pains in the epigastric, umbilical, or iliac regions ; in simple 
cases, the latter symptoms rarely last more than a short time, and when 
other\Yise they are almost always the sign of some complication. The 
constipation which exists during the initiatory stage generally continues 
throughout the disease, though in some instances a slight diarrhoea occurs 
about the end of 'the first or second week, after which the bowels regain 
their natural condition. If severe diarrhoea should make its appearance, 
it is almost always the sign of a dangerous complication. The nausea and 
vomiting which are so often present during the initial stage, cease after the 
appearance of the eruption, and recur only in rare cases, or in consequence 
of some complication. The appetite is almost always lost during the course 
of the disease, though it sometimes returns in the period between the ter-* 
mination of the initial and the commencement of the secondary fever; 
thirst is acute as a general rule, and more or less so according to the vio- 
lence of the fever. 

The urine presents, during the course of the disease, the ordinary febrile 
characters of lessened quantity and heightened color. The urea, uric acid, 
and pigment are increased, and the chlorides much diminished. Albumi- 
nuria is occasionally present at the height of the disease ; it is, however, 
temporary, and apparently not of very grave import. Casts of the renal 
tubules are also present in some cases. The frequency with which this con- 
dition exists probably varies in different epidemics, since we have detected 
it but rarely in our cases, while Parkes states that it is present in about 30 
per cent, of all cases. After the subsidence of the secondary fever, the 
urine frequently becomes very abundant, of pale color, and of low sp. gr. 
Thus, in one of our cases, in a girl aged 18 years, the daily amount of 
urine passed from the tenth to the thirteenth day of the eruption was f oclx, 
or ten pints, of sp. gr. 1001, as clear as spring-water, containing no albu- 
men, but with a fair proportion of chlorides. In another case, in a young 
man aged 20 years, the patient also passed, on the eighteenth day, f5clx 
of crystal-clear urine, of sp. gr. 1007, without albumen but containing 
abundant chlorides. In a third case, in a boy aged 13 years, the amount, 
on the twelfth day of the eruption, was foxlv. 

The strength of the child is not, as a general rule, greatly diminished, 
except in severe and dangerous cases. Restlessness, irritability, crt/ing, and 
delirium, which are of such frequent occurrence in the febrile diseases of 
children, are not usually very strongly marked in regular cases of variola. 
They exist, but it is to a modecate extent only. 

We pass on now to the confluent forms of the disease. 

It is not possible to predict from the character of the initial fever what 
is to be the type of eruption which is to follow, since in discrete variola, 
and even in varioloid, the preeusory fever and other symptoms, often run 
alarmingly high, while, on the other hand, a case destined to be confluent, 
or even htemorrhagic, does not always exhibit violent phenomena at the 
onset. As the time for the eruption approaches in confluent eases, the 
skin usually gives evidence of active inflammation of its deeper structures. 
It becomes thickened, swollen, hard, dark in tint, and as the eruption ad- 
vances, the countless number of papules and vesicles, which coverall parts 



SYMPTOMS. 795 

of the body, increase the violence of this inflainniatory action, and give 
rise to au earlier appearance of the secondary fever, which is marked by 
higher terajx^ratnre, more active delirium, and greater disturbance of the 
circulation than in discrete or moderate small-pox. As the vesicles form 
upon the papules, they so crowd the surface that their edges run together, 
thus making the confluence, and no portions of natural skiu remain on 
which to form the areolie, which therefore are absent. As the pustules 
follow the vesicles they do not develop well, but remain flattish and slug- 
gish, with a whitish, ill-concocted pus on some i)arts of the body, par- 
ticularlv the face and backs of the hands. Thev run together into larjre 
tlat blebs or bulla?, of several inches or more in extent. Sometimes 
portions of the loosened cuticle are rubbed off by the movements in bed, 
or by scratching. The parts thus denuded look raw, and exude a sanious 
fluid. 

In severe confluent cases the eruption extends to the mucous membrane 
<tf the nose, mouth, fjiuce^s eyelids, and perhaps to the prepuce or vulva, 
as in the distinct form, but with very diflerent severity and conseciuences. 
The inflammation produced by the eruption causes enlargement of the 
tongue, swelling of the fauces, pain, and often great difficulty of swallow- 
ing. The rawness and soreness of the passages, and an abundant and 
usually dark-colored viscid secretion, which clogs and clings to the parts, 
cause great distress, and add to the exhaustion of the patient. At the 
^ame time the laryngeal catarrh causes cough, hoarseness, partial or total 
loss of voice, and difficulty of breathing. Thus, as in violent anginose 
-carlet fever, and in some cases of diphtheria, the supply of air to the 
lungs is so diminished by the various causes of obstruction (swelling, col- 
lections of viscid phlegm, and spasm of the glottis) that the blood does not 
receive its due amount of oxygen, a venous stasis is established, the skin 
becomes dark-brown or purplish from capillary stagnation, and the patient 
dies, sometimes in great distress, though at others with very little apparent 
-uflering, in a state of asphyxia and exhaustion. 

In some cases the heart presents evidences of disease ; the sounds become 
feeble and obscure, the impulse weak, and the action of the heart irregular 
and intermittent. These symptoms, to which sjK'cial attention has been 
called by Desnos and Huchard,' are dependent upon grave inflammatory 
changes, either in the endo- or pericardium, or frequently in the muscular 
' - !' of the heart. In cases where this latter lesion is present they have 
i-ionally ob^erved a want of agreement in frequency between the con- 
tractions of the heart and the radial pul.se; and also, but as a much more 
eonstant sign, a murmur at the apex of the heart, soft, deep, difflise, and 
inconstant, which difl'ers in it* chariicter from the murmur which attends 
endocarditis of the valves. Undoubtedly in many cases of variola where 
death occurs suddenly, with signs of failure of cardiac power and pulmo- 
nary engorgement, the fatal event will be found ta depend on the develop- 
ment of one of these cardiac lesions, and especially of myocarditin. 

There b a form of confluent «mnll pox called snperfiejal confluent, in 



• DeS OOIDpliCStiOnn < aruKi-jW";." <jiiii.-« m »mii'>i. , I'dii-, 1^1 1. 



796 SMALL-POX. 

which, though the eruption is really confluent, it runs through the stages 
of maturation, desiccation, and desquamation so rapidly that the con- 
stitution is not greatly tried, and the patient recovers without difliculty. 

Even in the severe form, the patient may, if his constitution be good, 
pass safely through the disease. 

The liwinorrhagic, malignant, ov petechial form is happily rare. We had 
rarely seen it until the epidemic of 1871-72 showed it to us in all its ter- 
rible power. Our forefathers knew all about it. We, of the generation 
which has risen since the introduction of vaccination, had read of it, but 
took little heed of what the variolous poison might do when it exerted its 
malignant forces. In this form the patient is weak and feeble from the 
beginning. The surface assumes a singular reddish hue as the eruption 
comes out. The vesicles when they form upon the papules, instead of 
filling with lymph, and then pus, contain only a thin, sanguinolent liquid ; 
they mature very imperfectly, or rather not at all, not acuminating but 
remaining flattish, or irregular in shape, and flabby. While the eruption 
is struggling along in this irregular mode, the vessels of the cutaneous 
tissues become gorged and partially stagnant, so as to give to the surface 
dark red, brown, blue or purplish, and livid tints. Extravasations take 
place amongst and beneath the eruptive points, the cuticle forming the 
bloody pocks breaks, blood exudes, and forms dark scabs, and the patient 
is so changed from his natural aspect that we may comprehend how in the 
olden time, people who had not the consolation which vaccination gives, 
may have been driven from the bed and even from the house of the sufferer 
in hopeless terror. Such cases look no longer human. The swollen face, 
purple or black, the dark or crimson-red eyeball, with the whitish cornea 
sunken into a pit formed by the projection of the blood-colored and 
cedematous conjunctival membrane, the eyelids thick and stiff' and im- 
perfectly closing, the gross body, changed from all its natural bright to 
blackish tints, the cuticle dissected from the skin by bloody exudations, 
which weep and stain the clothing and bed-linen. Such is the variola 
nigra or black small-pox of the old writers, and well does it deserve its 
name. 

Varioloid, or Modified Small-pox. — This is a term now usually 
applied to the modified form of the disease, as it occurs in individuals who 
have been vaccinated, or who have already had the natural or inoculated 
disease. 

Dr. Welch's rule is a very good one, — " to- classify as variola all un- 
vaccinated cases, no matter how mild, all malignant cases, and all the 
vaccinated cases in which the eruption does not reach maturity until after 
the sixth or seventh day from its first appearance." The true point of 
distinction here, when any uncertainty as to vaccination exists (and this 
is not rare amongst the poor), is the time of maturation of the eruption. 
This, in varioloid, ought to be matured and in the decline by the sixth or 
seventh day. 

The initial symptoms of varioloid are of the same general kind as those 
of natural small-pox, differing merely in degree. But the physician ought 
to know that, in a few cases of even very mild varioloid, while the erup- 



VARIOLOID, OR MODIFIED SMALL-POX. 797 

tiou is destined to be sparse, to consist of but few pocks, ami to run throui;h 
its stages in five or six days, the initial fever may be very hiii:h, and the at- 
tendant phenomena of pain, nervous disturbances, loss of strength, etc., 
very marked. We once saw a girl nine years old, who was ill for three 
days with very high temperature, delirium, stupor, prostration of strength, 
violent headache, and rapid pulse, so that her case looked very threaten- 
ing, and left the diagnosis in great doubt. On the third day a moderately 
abundant variolous eruption came out, when all the unpleasant symptoms 
rapidly abated and disappeared. The eruption ran through its stages in 
six days, and the patient recovered without a pit. 8he had been well and 
carefully vaccinated in infancy. 

These severe initial symptoms are rare, however, in children as com- 
pared with adults. Usually the attack begins with slight fever, head- 
ache, languor, and sometimes constipation, which are followed in two or 
three days, by the eruption. The vomiting, lumbar pains, and different 
nervous symptoms which exist in regular variola, are not often present, or, 
if so, iu a very slight degree. The eruption consists of papules like those 
of true small-pox, but usually they are few in number, and entirely dis- 
crete in their arrangement. The initial fever and other symptoms subside 
completely upon the appearance of the eruption, and the child often seems 
perfectly well. 

The progress and character of the eruption are very similar to those of 
the regular form of the disease, with the exception that the changes are 
more rapidly effected, and, as a consequence, the duration of the attack is 
rendered by so much the shorter. The papules are converted into vesicles 
at a much earlier period — as early as the first or second day. The vesicles 
soon assume a whitish, opaline appearance, become umbilicated, and in the 
course of the second or third day begin to change into pustules. The sup- 
purative stage of the eruption, or maturation, is seldom accompanied by any 
marked .secondary fever, as in the regular disease. When the fever does 
occur, it is generally very moderate, consisting merely in slight accelera- 
tion of the pulse and a little increa.sed heat of skin, and in one or two 
days it disappears entirely. The pustules do not fill usually so well as in 
regular variola, and not unfrequently their contents are rather sero-puru- 
lent, than purulent, in the proper sense of the term. The tliird stage 
occurs earlier and goes through its periods more raj)idly than in true small- 
pox ; de-iiccation soon takes place, is speedily finished, and the falling of 
the scabs, which begins as early as the eighth day of the eruption, is usu- 
ally completefl about the twelfth or fourteenth. After de-cjuamation is 
completed, the only traces of the disease left are reddish spoU^ or blotches, 
which disappear after a time without leaving cicatrices. The whole dura- 
tion of the attack is generally from ten to twenty days. 

Varioloid may be so mild that the patient never goes to bed. Some ma- 
laise, a little loss of appetite, the appearance on the skin of half a dozen 
papules, which soon become umbilicated vesicles, and then rapidly form 
scabs, con.«titute the whole history of some cases. Here it is that a correct 
diagnosis is invaluable to the family. To the patient it is of no consequence. 



798 SMALL-POX. 

He is safe, but he may inoculate any or all of those who have not been 
properly protected. 

Complications. — The most frequent and important complications of 
variola in children, are inflammations of the mucous membrane of the 
lower half of the intestinal tube, ophthalmia, otitis, and different hsemor- 
rhages. In a smaller number of cases, attacks of bronchitis, pneumonia, 
anasarca, articular inflammations, subcutaneous abscesses, simple and 
pseudo-membranous coryza, angina, and laryngitis, and other eruptive 
diseases, occur at different periods of the malady. 

It is impossible for us, for want of space, to attempt a description of 
the various symptoms of the diflTerent complications just enumerated. 
Having mentioned the possibility and probability of their occurrence, 
we must leave the reader with the advice always to suspect the existence 
or approach of some one of them, when the symptoms, in any case, differ 
much from those which have been described as characteristic of the regu- 
lar form. 

Anatomical Lesions. — The characteristic lesions of small-pox are a 
certain deteriorated state of the blood, congestion of the internal organs, 
and the inflammation of the skin and mucous membranes constituting 
the eruption. The blood is found to be entirely liquid and uncoagulable, 
and of a dark color; or if coagula exist, they are small, soft, and very 
dark in color. The exceptions to this rule are those in which some acute 
and severe inflammation exists, under which circumstances the dissolved 
state of the blood is less marked, and fully formed coagula are more 
abundant. The congestion referred to aflTects almost the whole system. 
The muscles are firm and of a deep red color; the membranes of the brain 
are strongly injected, the sinuses are filled with blood, and the cerebral 
substance presents numerous red points or dots. The vessels of the lungs 
contain a large quantity of blood, and the liver, spleen, and kidneys, are 
all deeply congested. 

The condition of the mucous membranes is important. The pharynx, 
larynx, and trachea, present an eruption, or simple inflammation without 
eruption. The eruption exists under the aspect of small, circular, thin, 
and whitish pseudo-membranous points, scattered over the mucous tissue, 
and slightly adherent to it, beneath which that tissue is often observed to 
be red and inflamed. At a more advanced degree, and in severer cases, 
the false membranes have disappeared, and in their places we find circu- 
lar ulcerations, which are either superficial, or they penetrate the tissue of 
the mucous coat and rest upon the muscular, or even pierce that and reach 
to the cartilaginous tissue beneath. In addition to these lesions are found 
inflammation of the mucous tissue with its consequences, redness, soften- 
ing, thickening, and extensive deposits of false membrane, quite distinct 
from the appearances above described as characteristic of the eruption 
upon these tissues. 

It has been a contested point whether a true vesicular or pustular erup- 
tion ever exists upon the mucous lining of the stomach and intestines. 
The general opiuiou appears now to be, however, that the changes ob- 
served in these organs cannot be ascribed to the formation either of ves- 



DIAGNOSIS. 799 

icles or pustules. The appearances that have loil some observers to con- 
sider them as the result of a proper eruption, are the tuUowinp The 
follicles at the commencement and termination of the small intestines, 
and in rarer cases, of the large intestine also, present an abnormal degree 
of development, appearing in the form of small hemispherical or pointed, 
and sometimes llaitened projections, on which there often exists a dark, and 
sometimes depressed central point. At the same time Peyer's glands are 
often enlarged, more projecting than usual, softened, and red. 

According to the valuable researches of Desuos and Huchard {loc. cif.), 
the heart and pericardium present marked lesions in a considerable i)ro- 
portion of cases of confluent variola. These changes were rare in cases 
of the discrete form, and were not delected in any case of varioloid. The 
lesions may consist solely of endocarditis, or pericarditis, or these may be 
associated. These inflammations present the ordinary morbid products, 
and are not attended with the development of pustules. In other cases, 
the muscular walls of the heart are aftected with an acute myocarditis, 
which is marked at first by a granular state of the muscular fibres, which 
soon passes into fatty degeneration. 

The anatomy of the variolous pock is important and interesting. When 
a vesicle is opened soon after its formation, it is found to contain nothing 
but a little serosity, which is perfectly limpid and alkaline, while the skin 
beneath is red, softened, and moist. The umbilicated character depends 
on a filiform adhesion between the centre of the pock and the surface of 
the skin beneath. This adhesion is broken, when, at a later period, the 
pustule becomes globose in shape. The vesicle is also subdivided into 
several chambers by delicate radiating partitions, so thata single puncture 
will not discharge the entire contents. About the period of the conversion 
of the vesicles into pustules, or very soon after the formation of the latter, 
the cavity of the pock will be found to contain a false membrane, which 
is of an opaque white color, soft and friable in it-s texture, and seated 
upon the derm in small isolated points. After a time these points enlarge, 
and meeting, unite, and form a soft pseudo-membranous disk, uneven 
upon its surface, and which either fills the pock completely, or is covered 
at first with serosity and afterwards with pus. This false membrane is 
secreted originally by the true skin. At a somewhat later period it 
forms an adhesion to the inner surface of the cuticle, while still later in 
the progress of the pock, it becomes detached from the cuticle, and re- 
mains loose and free in the cavity of the pustule, siirrounded by the fluid 
contents of the latter. 

Diac;no**is. — The diagnosis of this di.sease in all its forms ought to be 
made as early as possible, in order that the persons in contact with the 
patient, whether from necessity or by accident, may be vaccinated or re- 
vaccinated. It is well known that expfwure to the mildest varif)loid may 
prf>duce in the unprotected any form of small-fK)X, from discrete to malig- 
nant, according to the constitution of the subject and the type of epi- 
demic prevailing. Therefore the only safety after expf)8ure is in the 
vaccine di.sea.se, and, therefore, the lives of the exposed hang upon the 
knowledge and action of the physician in charge, a resiKjuuibility from 



800 SMALL-POX. 

which he cannot escape either in the estimate of the public or in his own 
consciousness. 

Dr. Welch concludes from his observations that " vaccination performed 
at a period less than seven days previous to the appearance of the eruption 
(small-pox) will not modify the disease," but that when performed "seven 
days previous, (it) will almost always modify the disease to the extent of 
rendering it harmless." 

Dr. Masson (article on Small-pox, in Reynolds's System of MecUcme, 
vol. i, p. 477) says that to be effective vaccination should have gone on to 
the stage of areola before there is any illness from small-pox. " It has 
before been stated that when small-pox has been taken into the system 
there is twelve days' freedom from illness, generally, forty-eight hours' 
illness, and then the disease begins to appear on the skin. The areola of 
vaccination is not fully formed until the ninth or tenth day of the progress 
of the vaccine vesicles on those who have never been vaccinated before, 
so that unless there has been time for the areola to be formed after the 
vaccination, before the illness produced by small-pox begins, the vaccina- 
tion will not be of the least benefit." He gives an example : " Suppose 
an unvaccinated person to inhale the germ of a variola on a Monday ; if 
he be vaccinated as late as the following Wednesday, the vaccination will 
be in time to prevent the small-pox being developed ; if it be put off until 
Thursday, the small-pox will appear, but will be modified; if the vac- 
cination be delayed until Friday, it will be of no use, it will not have had 
time to reach the stage of areola, the index of safety, before the illness of 
small-pox begins. This we have seen over and over again, and know it 
to be the exact state of the question. Revaccination will have effect two 
days later than vaccination will have that is performed for the first time, 
because revaccinated cases reach the stage of areola two or three days 
sooner than in those persons vaccinated for the first time." 

It is plain, therefore, that the diagnosis ought to be made as early as 
possible. Can it be made in the initial stage? Not, we think, with any 
certainty. Except in a time of general epidemic prevalence, cases of 
small-pox are almost unknown, and varioloid is very rare amongst chil- 
dren, and the medical man thinks of anything but varioloid or small-pox 
to explain a fever attended with vomiting, anorexia, restlessness, or drow- 
siness in the infant, and the same symptoms with headache and general 
soreness in the older child. The initial fever has no characteristic phe- 
nomena. When the disease is epidemic, the initial fever, as it has been 
described, may arouse suspicion, and the attendant physician may dare to 
announce the probable approach of the dreaded disease, and examine all 
the exposed persons as to their being fully protected. But this course is 
justified only by the presence of the epidemic. Not until the eruption 
begins to appear can the diagnosis be made with certainty ; and however 
easy it may be for old and experienced physicians to make it then, we 
desire to caution the youuger and more inexperienced as to the possibility 
of mistake. 

The important points to bear in mind are the following : 1. The pro- 
dromic stage, whether of mere ailing and lassitude, such as may not send 



I 



DIAGNOSIS. 801 

the patient to bed, or violent fever with nervous symptoms and the differ- 
ent signs which declare a severe disease, which lasts two days, and on the 
third of which, as the law, the eruption makes its appearance. 2. The 
eruption appears first on the face and about the upper part of the neck, 
and consists of hard, distinct, shotty papules, seated, in mild cases, on a 
nodosal skin. 3. As the eruption appears, the fever diminishes. These 
three points kept steadily in view will usually prevent any mistake. 

The eruption of me<asles shows itself on the third day of fever, as in 
small-[X)x, and occasionally appears in distinct points, which give it a sus- 
picious likeness to that disease. But the attendant catarrhal conditions, 
the coryzii, cough, and conjunctival catarrh, with the fact that the fever 
increases as the eruption comes out, instead of diminishing as in variola, 
ought alone to decide between the two. ^loreover, a careful study of the 
eruption ought to enable us to decide. In variolous disease the papules are 
small, hard, very distinct one from another; in measles the papular char- 
acter is not well marked, the stigmata are larger, broader, flatter, and 
much less hard and shotty to the the touch, and very soon they run to- 
gether and assume irregularly crescentic outlines. By the second day of 
the disease there is rarely any difficulty. 

Varicella, which from its name, one would think, ought to resemble va- 
riola closely, has rarely given us any trouble. The prodromic stage of 
varicella never lasts over a day; it often consists of but a restless night, 
and sometimes the first thing to attract the attention of the mother or 
nurse is the eruption. When the prodromic stage does exist, it consists 
merely of some lassitude or irritability, loss of appetite, and slight fever. 
The eruption shows itself at once upon the face and front and back of the 
body. So much is this the case that we always have the child undressed 
in order to get a good view of the body. If, on inspection, a number, 
three or four or a dozen, or very many rounded; projecting, globose vesi- 
cles are to be seen, consisting of a thin and transparent layer of the cuticle, 
filled often to bursting with a limpid serum, there ought to be no difficulty 
in the diagnosis. Such an eruption, appearing with scarcely a prodrome, 
or merely a slight ailing of twelve or twenty-four hours, cannot be small- 
pox or varioloid. 

In very mild varioloid, where the eruption counts three or four or half 
a dozen vesicles, and where the prodromes are very mild, it is not always 
easy to be quite .secure in one's opinion, and a careless or inex|>erienced 
person might very well fail to detect the true nature of the disorder. But 
even here careful inquiry will generally show that the health has been dis- 
turbed for two days, at lem^i by altered temjK'r, lassitude, lessened ap|)e- 
tite, and one or two restless nights. These pro<Jromes, when followed by a 
few hard, distinct papules, which become on the second day vesich^H, and 
then umbilicated pustules, to dr>' up on the fourth, fifth, or sixth, can be 
nothing but variolous in their nature. 

Again, in severe cases of small-pox iL**elf, embarrassments sometimes 
occur. We once saw an infant, five weeks old, who had never been out of 
the mother's rfxjm, seized in the midst of perfect health, with violent fever, 
vomiting, loathing of the breast, and heavy stupor. On the second day of 

61 



802 SMALL-POX. 

the illness the whole cutaneous surface began to redden ; soon the tint be- 
came bright-red, not unlike some scarlet fevers, but of a more crimson- 
red; the skin was swelled, tight, hard, and, so to speak, shining. On the 
third day innumerable hard and distinct papules formed upon this evi- 
dently acutely inflamed skin, and on the following day the child died co- 
matose. The child had not been vaccinated, and there were at the time a 
few cases of varioloid and small-pox in the city. Even in such cases, how- 
ever, where a deep roseolous or erythematous efflorescence precedes and 
masks the variolous eruption, the violence of the prodromic symptoms, so 
unlike the mild phenomena which precede ordinary roseola or erythema, 
and particularly the intensity of the coloration and the hard and swollen 
condition of the skin, indicating active inflammatory states of its deeper 
layers, will go far to prepare an experienced eye for what is coming. 

Prognosis. — The fatality of small-pox varies greatly in different epi- 
demics. The result is also markedly influenced by age. It is particularly 
fatal in infants under one year of age. Of the whole number of cases, 
2377, admitted into the Municipal Hospital of this city in 1871-2, there 
were 35 children under one year of age. Of these 26, or 74.28 per cent., 
died. Between the ages of 1 and 15 years there were 291 cases, of which 
95, or 32.64 per. cent., died. The mortality was therefore nearly three- 
fourths of the whole number under one year, and very nearly a third of 
those between 1 and 15 years of age. 

Of a series of 23 cases that we have met with, 5 were fatal. All of these 
were under 5, and 3 under 1 year of age. 

The amount of the eruption governs the prognosis to a great degree. 
As the number of pocks is abundant or otherwise, — as the case is a dis- 
crete, moderately full, semi-confluent, or confluent one, — so is the danger. 
Cases of full confluence are almost as fatal as malignant scarlatina. Few 
children escape in the confluent form. A moderately full eruption, and 
of course a discrete one, is favorable. The hsemorrhagic form is, almost 
without exception, fatal. Varioloid rarely kills. Under 15 years of age 
we have never seen a fatal case of it. In one case only have we known it 
to be dangerous. 

The favorable symptoms in any case of variola are the occurrence of 
the disease in children previously in good health and over one year of age; 
the absence of any violent nervous symptoms during the initial stage ; a 
proper duration of the first stage ; and the subsidence of the fever after the 
appearance of the eruption. When, in addition to these circumstances, the 
secondary fever is not too violent, and no complication arises, there is but 
little doubt that the patient will recover. 

The unfavorable symptoms are the occurrence of the disease at a very 
early age; the existence of severe nervous symptoms during the first stage ; 
the occurrence of a thick and abundant eruption upon the face indicating 
a probably confluent case; continuation of the fever after the appearance 
of the eruption, or a merely slight subsidence of it ; delirium and other 
nervous symptoms during the secondary fever; and any irregularity in the 
appearance of the eruption, as paleness instead of the usual red color, a 
livid or purplish color of the pustules, imperfect development of the 



i 



TREATMENT. 803 

pocks, or their sudden shrinking without diminution of the general symp- 
toms. The occurrence of the signs which mark the hiemorrhagic form, as 
petechia? and local htvmorrhages, stamp the case as almost necessarily 
fatal. It is scarcely necessary to si\y that many of these symptoms are 
indicative of the existence or threatened production of some complica- 
tion, upon the nature of which must depend, after all, in great measure 
our prognosis. The complications most apt to occur have already been 
considered in a previous section. 

Treatment. — The treatment must be regulated by the type of the case 
under charge. It will vary, therefore, from a mere quiet expectancy 
throughout, to the vigorous use of such means as moderate fever, abate 
nervous agitation, and allay suffering in the early stages, with the peremp- 
tory exhibition of stimulants!, tonics, and nutritious foods, in the period of 
eruption and maturation. 

In the varioloid of children over eight or ten years of age, during the 
initial fever, rest in bed, light diet, and the use of sweet spirit of nitre, in 
iced lemonade, often suffice. Should there be much restlessness, insom- 
nia, or pain, solution of citrate of potash, with small doses of laudanum 
or paregoric, may be given. When the eruption appears, if it be slight, 
and the fever disapi)ears, nothing more is necessary than to keep the diet 
moderate and seclude the patient in one room, for the sake of others, 
until the crusts have fallen. If the eruption be more copious, enough to 
cause a good deal of irritation and restlessness, a warm bath at night, es- 
pecially with some bran added to it, and the aj)plication through the day 
of an ointment of glycerin and cold cream, with a mild opiate at night, 
are all-sufficient. 

In the variola of un vaccinated children, the treatment must also depend 
on the type of the symptoms. In the initial stage, when the fever is high, 
the child must be confined to the breast, if it is still nursing, and, if weaned, 
it is to be kept upon a proper mixture of milk and water, with lime-water, 
and upon chicken or beef tea, for food. Cold water must be frequently of- 
fered to the child at all ages, and it should be allowed to take all it desires. 
A tepid bath morning and evening, or even three times a day, if the child 
does not resist, is very soothing, and tends to reduce the heat. Spongings 
with tepid or cool water, from time to time, according to the degree of heat, 
and the effects of the application, may l)e used, if the bath terrifies or fails 
to reduce the fever. 

Diaphoretics, and especially the citrate of pota.sh, with sweet spirit of 
nitre, and very small proportions of laudanum, should be administered in 
this stage. f)r the spirit of Mindererus may he given, — twenty to thirty 
drops, with ten dro[)s of nitre and five of paregoric, in a tablespoonful of 
iced water, every two hours, to children of six months to two years. For 
older children the doses must be enlarged. 

When there is, as often happens, great agitation of the nervous system, 
as shown by jactitation, insomnia, anri mild or active deIiriunj,some remedy 
should he given to control the.«e symptoms. If the citrate of potaf^h and 
opium fail to relieve these conditions, the best remedy is bromide of potas- 
sium, one to two and a half grains, with one to two drops of demJorized 



804 . SMALL-POX. 

laudanum, at the age of one to three years, every two hours until rest is 
obtained, or until three or four doses have been given. After the age of 
four years the proportion of the bromide may be doubled. 

When great heat and swelling of the skin, severe headache, and signs 
of congestion of the lungs or brain, exist, cold applications to the head, 
with hot mustard foot-baths, may be used with the diaphoretics. If, in 
older children, the headache or pain in the loins be very severe, a few dry 
cups or a sinapism may be applied to the back of the neck or loins. 

If the bowels are not moved spontaneously, a moderate laxative ought 
to be used, as syrup of rhubarb or castor oil, or an enema may be ordered. 
Purging with large doses of cathartics must be avoided at all ages. 

In the eruptive stage the treatment must vary with the type of the erup- 
tion and the constitutional peculiarities of the patient. It may be laid 
down as a rule that, the more copious the eruption, the more carefully 
should the strength be husbanded, and the vitality supported, to enable 
the patient to pass through the long and exhaustive processes of matura- 
tion and desiccation necessary to a cure. 

If the eruption come out slowly and tardily, and the extremities be cool, 
even though the body is hot,, hot mustard foot-baths, or warm baths, with 
hot drinks, as milk and water, hot broths, and small quantities of brandy, 
ought to be employed, and are often very useful. 

If the eruption be discrete and moderate in amount, nothing but rest in 
bed, simple sustaining foods, and some local remedy to allay cutaneous 
irritation, as an ointment or an occasional warm bath, will be necessary 
until the secondary fever appears. When this arrives, the same means, in 
the form of diaphoretics, anodynes, and nervous sedatives, should be used 
as in the initial stage. In the stage of maturation the strength must be 
sustained by a diet adapted to each particular case. If the patient be 
feeble, and therefore much reduced by even a moderate eruption, he must 
have brandy added to his milk, or wine-whey, from time to time, increased 
doses of beef or chicken soup, if he can take them, and, if old enough, 
eggs, or egg-nog. Quinia and muriated tincture of iron should be used as 
in confluent cases, of which we shall speak directly. 

In the semi-confluent and confluent cases all must be done to sustain the 
strength and vitality. From an early period of the eruptive stage, alcohol, 
quinia, and iron, must be employed. From twenty to thirty drops of 
brandy, in a wineglassful of milk, may be given every two hours, and two 
or three tablespoonfuls of thin beef tea, every alternate two hours, at the 
age of two or three years. After the age of five, these quantities may be 
doubled. To infants, brandy, in doses of ten to twenty drops, may be 
given every two hours, in breast-milk, or in warm water and sugar. Quinia, 
in doses of half a grain, at a year old, and one grain at four and five years, 
with or without muriated tincture, of iron, ought to be administered every 
four hours. It is best to choose the four-hour interval, because of the diffi- 
culty there is in giving frequent doses to children. If the stomach will 
not retain the iron and quinia mixed together, the quinia may be used in 
suppository, two grains every four hours, and the tincture of iron in doses 
of two to five drops, according to the age, every two hours, in syrup of 



TREATMENT. 805 

ginger, or in combination with dilute acetic acid and solution of acetate 
of ammonia, as proposed in the article on scarlet fever. On account of 
the well-known frequency of cardiac complications in such cases, digitalis 
may be added to the treatment if the symptoms indicate marked failure of 
the heart's action. 

The condition of the pharynx and larynx present in confluent small-pox, 
as described in the article on symptoms, constitutes one of the great diffi- 
culties of the disease. The patient sutlers so much in the act of swallowing, 
the respiration is so interfered with when he attempts to drink or eat, that 
it ends in his taking but little, and, at last, almost nothing. Here ice 
should be given, iced tlaxseed tea and iced brandy and water, or frozen 
beef tea. A solution of chlorate of potash may also be tried. Lemonade 
may be used, and a warm poultice to the throat is to be recommended. 
Still we must persevere, as small quantities are better than nothing, and 
we may employ nutritive injections of beef tea, of milk, or of eg'^ and 
milk. 

Jf the patient survives the stage of eruption, we must continue the tonics, 
stimulants, and nutritious food through the decline of the disease. During 
the latter period something must be done to allay the itching, burning, and 
irritation of the skin. If the patient is not too weak, a flaxseed or bran 
bath is very soothing, or we may use lime-water and sweet-oil liniment, or 
glycerin and cold cream ointment, applied with a large camel's-hair brush 
frequently. 

In ha^morrhagic small-pox, which is almost always fatal, we know noth- 
ing better to recommend than the treatment just advised for the confluent 
form, to which turpentine in full doses may be added, on account of both 
its stimulant and luemostatic properties. 

Treatment of Complications. — If complications occur in the course of the 
disease, they must be treated always with a full consideration of the pri- 
mary importance of the general disorder. The angina and laryngitis of 
confluent cases can scarcely be looked upon as complications. They be- 
long to the disea.se. We have already alluded to their treatment, and may 
refer the reader to what has been said of the same series of symptoms in 
scarlet fever. In pleurisy or pneumonia we can do nothing better than 
persevere with the measures most proper to combat fever. Pain may make 
it necessary to use opium in full doses. Counter-irritation is not to be 
thought of becau.«e of the eruption, and even cataplasms, which are so 
useful in ordinary pleurisy and pneumonia, are objectionable here. 

The treatment of the ophthalmia which so often threatens, and some- 
times occasions great or irreparable injury to the eye, is very important. 
Niemeyer says that much may be done to prevent the development of a 
severe eruption on the conjunctiva by the assiduous employment of cold 
water compresses, or, still better, by compresses moistened with a weak 
solution of corro-sive sublimate, one of one grain to six ounces of distilled 
water. When ulcerations occur upfm the cornea, they ought to be touched, 
if this be practicable, with solid nitrate of silver sharpened to a point, or 
with a fine carael's-hair pencil which has been moistened and rubbed over 
the nitrate of silver crystal to insure a cauistic solution. When it is im- 



806 SMALL-POX. 

possible to apply the solid caustic or the brush, we must resort to some 
collyrium. This may consist of a solution of nitrate of silver, a grain to 
the ounce, or of one or two grains of sulphate of zinc, with twenty or thirty 
drops of wine of opium, dissolved in an ounce of rose-water, two or three 
drops of either of which may be introduced into the eye, morning and 
evening. An excellent collyrium is one composed of twelve grains of 
borate of soda, one grain of sulphate of zinc, a drachm of camphor-water, 
to seven drachms of distilled water. 

Catarrh of the intestine must be treated by the most careful attention 
to the diet, by emollient and anodyne injections, and by the internal ad- 
ministration of astringents, and small doses of opiates. When the diar- 
rhoea is severe, and the stools mucous and bloody, we may use with ad- 
vantage the nitrate of silver by enema, as recommended in the article on 
entero-colitis. 

The treatment of the convalescence is important. The same rules apply 
here as in other infantile and children's diseases. 

Ventilation and Disinfectants. — It is even more important in this disease 
than in others, for the physician to see to it himself that the rooms occu- 
pied by the patient, and the house of which they form a part, shall be well 
ventilated, and that so soon as the eruption becomes purulent, and its 
exhalations more or less fetid, proper disinfectants shall be applied. This 
is necessary, not only for the good of the patient, but also for the safety 
and comfort of the other inmates of the house. The best ventilation in 
winter is that procured by an open fire, or, if this cannot be had, by a 
stove. If the room can be warmed only by a furnace, the windows must 
be very carefully opened from time to time, so as to supply fresh air, and 
yet avoid currents flowing over the patient. In summer, of course, the 
windows must be open. 

Among the best disinfectants is Labarraque's solution. If this cannot be 
bad, or if more than one be desired, chloride of lime in saucers, wetted, or 
a mixture of equal parts of impure sulphate of iron and of chloride of lime, 
wetted, and placed in saucers, in the entries and passages of the house, 
are very efficient. Solutions of carbolic acid or permanganate of potassa, 
chloral um, and other disinfectants may be substituted for the above if 
more convenient. 

Before terminating our remarks upon the subject of small-pox, it will 
be proper to give some account of the treatment of the eruption which has 
been recommended and practiced, with a view to prevent the scarring and 
disfiguration which so often result from the ravages of the disease. Of the 
different means that have been employed with this view, there are two 
which are chiefly relied upon at present. One is to cauterize the pustules 
with nitrate of silver, and the other to make a mercurial application upon 
the part where it is desirable to cause the abortion of the eruption. The 
cauterization has been performed in two modes : by the application of the 
caustic to each pustule separately, or to masses of the eruption without 
puncturing the cuticle. It appears, however, that the first-named method 
is much the most preferable. To succeed perfectly, it is necessary to touch 



TREATMENT. 807 

the derm forming the base of the pustule ; so that the best plan is to re- 
move or lift up a portion of the top of the vesicle with a lancet, and then 
to introduce into its interior the sharpened point of a stick of caustic. 
This operation is certainly successful only when performed on the first or 
second day of the eruption, though MM. Killiet and Ixirthez have known 
it to answer as late as the third and fourth, or even fifth day. The pro- 
cess of cauterization is productive of acute pain, but does not increase the 
local infiammation, according to the authors just quoted, at least when 
applied to a small number of the pocks. They state that when apjdied to 
the pustules seated upon the edges of the eyelids, it is almost incredible to 
behold how great is the diminution of the oedema of those parts in a single 
day. The conclusion of these gentlemen is, that individual cauterization 
of the pustules with nitrate of silver does certainly cause them, as well as 
the surrounding tumefaction, to abort, and prevents them from leaving 
cicatrices. 

This plan is, however, manifestly inapplicable to any but cases of the 
discrete form, where the vesicles are not very numerous. 

The other method which has been employed to cause the abortion of the 
pustules, and thus prevent di.-figu ration, is, as has been stated, the applica- 
tion of some one of th(i mercurial preparations. The effects of this treat- 
ment are said to be an almost certain arrest of the development of the 
eruption, when it is used from the first or second, or not after the third 
day ; the vesicles and pustules remaining small and isolated, and not as- 
suming, or else soon losing, the umbilicated character. When applied 
early, while there are as yet but few vesicles formed, it prevents the de- 
velopment of new ones, and diminishes the accompanying swelling and 
soreness. When the application is removed on the seventh or eighth day, 
it is found that desiccation has occurred imperfectly, the surface present- 
ing small soft scabs, or little whitish, soft elevations, consisting of the 
pseudo-membranous substance situated between the true skin and the new 
epidermis, the old cuticle having generally peeled ofl^ with the plaster. In 
some places a light rose-colored surface alone remains. 

In regard to the success of this treatment in preventing disfiguration, we 
may quote the statement of MM. Killiet and Barthez, that none of the 
patients upon whom they saw it tried presented any cicatrices, though sev- 
eral had had confluent small-pox, which pursued its usual course on the 
parts not covered by the application. Dr. Stewardson, of this city, made 
a considerable number of trials of this treatment at the 8mall-pox Hos- 
pital of this city in 1841-42. He gave his conclusions in the following 
words (Am. Jour. Med. Set., January, 1843, pp. 86-7): " From these ex- 
periments, it seems pretty evident that the mercurial plaster has a deeided 
influence upon the sraall-pox pustules, preventing more or less completely 
their perfect maturation, and dimini.shing the concomitant swelling and 
soreness, the process of desiccation being completed without the formation 
of thick scabs, and the resulting cicatrices le.ss marked than when tlu; |)ro- 

cess of suppuration was left to pursue its natural course That, by 

its use, pitting may be entirely prevented, or the mortality from small-pox 
materially les.sened, seems to me very doubtful, although had all the pre- 



808 SMALL-POX. 

cautions above-mentioned been taken, it is not improbable that the effects 
would have been still more decided." 

The use of the mercurial application is attended with some inconvenience. 
In the first place it is difficult to keep it accurately applied, particularly 
in children, in consequence of the unpleasant sensations it occasions. In 
the second place, it not very unfrequently, according to MM. Rilliet and 
Barthez, produces an eruption of hydrargyriasis or mercurial roseola, in 
about eight or fourteen days after the variolous eruption, or four or ten 
after the application of the remedy. M. Rayer, however, states this effect 
to be a rare one. 

Dr. Stewardson says that he thinks no apprehension need be felt as to 
constitutional affection from the mercury, for scarcely ever were the gums 
even touched. One of ourselves, however, when in Paris, in 1840, saw 
this effect produced in a young girl at the Children's Hospital. 

The method of its application is different in different hands. The 
French generally employ the emplastrum de Vigo cum mercuric. Dr. 
Stewardson prefers the strong mercurial ointment, either pure or rubbed 
down with an equal bulk of lard, spread upon a piece of thick muslin. 
The muslin is to be cut into the shape of a mask, with apertures for the 
eyes, nose, and mouth. It is secured upon the face by means of strings 
attached to its margin and tied across the back of the head and neck. It 
it important always for the success of the measure, that the application 
should be kept in close contact with the skin. To insure this, he employed 
a separate piece of muslin for the nose, which is the part most difficult to 
fit. With the same view, the French authors recommend that the plaster 
should be cut in pieces to suit the different portions of the face, making 
one for the forehead, and others for the cheeks, sides and back of the nose, 
and upper and lower lips. Any spaces that may remain are to be covered 
with other portions of the plaster, and the whole secured with strips of 
diachylon. On account of the difficulty of applying the mercurial plaster, 
the following ointment was compounded by the apothecary of the Chil- 
dren's Hospital at Paris, and has been found to answer very well : 

R. — Mercurial Ointment, 24 parts. 

Yellow Wax, 10 parts. 

Black Pitch, 6 parts. — Mix. 

The application ought to be confined to the face, as that is the part 
which it is most important to save from disfiguration, and as it is better 
not to use it upon a larger surface than necessary, lest it might occasion 
the mercurial roseola, or possibly salivation. As a general rule, four or 
five days are sufficient, according to Guersant and Blache, to leave it in 
contact with the skin, in order to avoid the bad effects just referred to. 

The object sought in these applications being, to a great extent, to pro- 
tect the vesicles from contact with the atmosphere, it has been advised to 
paint a saturated solution of gutta percha in chloroform, over the neck 
and face, so soon as the papular eruption is fully out. This plan was tried 
in five of our own cases {loc. cit, p. 345), two of which were discrete and 
three confluent, and with very satisfactory results. 



VACCINE DISEASE. 809 

To conclude this matter we will add that Niemeyer states that Skoda 
prefers impresses moistened with solution of corrosive sublimate (gr. ij-. 
iv to water .svj) to mercurial ph\ster, which induces an injurious elevation 
of ten»perature. He also says that Hebra rejects both mercurial plaster 
and solution of corrosive sublimate, a^ well as collodion, and touching the 
individual pocks with nitrate of silver, and that he has come to this de- 
cision from the observation in his wards, that the pocks do not leave 
cicatrices any oflener since he ha^ ceased to employ these remedies than 
when he used them. He (Hebra) applies only cold water compresses, 
which, while the skin is tense, relieves the patient, although they do not 
protect the skin from destruction. 



ARTICLE IX. 



VACCINE DISEASE. 



Definition; Synonyms; History. — The vaccine disease is an affec- 
tion produced by the inoculation of the virus of variola, modified by pass- 
ing through the system of the cow. 

The proofs which exist as to the truly variolous nature of the vaccine 
di.sease in the cow, are altogether incontestable ; so that we must regard the 
vaccine disease in the human subject merely as a remarkably modified form 
of variola. 

It is susceptible of propagation from individual to iudividual by inocu- 
lation, but is contagious in no other way, and it pos,sesses the invaluable 
quality of protecting, with very great, though not with absolute certainty, 
those through whom it has passed, against small-pox. 

Bivides the name given above, it is known by the titles of cow-pox, 
kiue-pock, vaccina, and vaccinia. 

Some knowledge of the nature of the vaccine disease, and of its power 
to protect the human constitution against small-pox, has been found to 
have existed in different part« of the world, but there can be no doubt that 
we owe to the genius and patient research of Dr. Jenner the inestimable 
blessing of vaccination, since it was by him that its marvellous virtue was 
demonstrated and pnK-laime<l to the world. Dr. Jenner learned, at an 
early period of his life, that there existed a popular belief in (tloueoster- 
Fhire, England, that persons who had contracted a peculiar vesicular dis- 
enne from the udder of the cow, were thereby protected from the attack of 
smallpox. Becoming convinced by a long course of patient observation, 
that this belief was foundeii in fact, he determined at last to try whether 
the disease might not be transmitted from one person to another, and thus 
iDcrea.ee immea.«urably the utility of this wonderful protective means. On 
the 14th of May, 1796, accordingly, he vaccinated a ehild eight years old 
with matter taken from the hands of a milker who had receive<l the disease 



810 



VACCINE DISEASE. 



from the cow. The experiment succeeded perfectly, the child having re- 
ceived and passed through the disorder iu the most satisfactory manner. 
On the 1st of July following, this child was inoculated with variolous 
matter, and resisted the contagion entirely, as Dr. Jenner had expected. 
It was not, however, until two years later, in 1798, after additional experi- 
ments, that the results of his researches were published to the world. From 
this time the belief in the utility of vaccination and its application in prac- 
tice spread rapidly throughout England. In 1799 it was introduced into 
this country; in 1800 it reached France, and in the course of a very few 
years extended to all civilized nations. 

Symptoms; Course. — It is very important for the physician to be thor- 
oughly acquainted with the appearances presented by the vaccine disease 
in its various stages, since he is to judge by those appearances whether the 
subject has had the disease in such perfection as to derive all the benefit 
from its protective power which it is possible for it to impart. 

The first efiect of the puncture by which the virus is introduced into 
the tissues, is to produce a very slight redness at the point where the ope- 
ration is performed. This redness usually disappears within twenty-four 
hours, and there is left merely a little mark or scab at the point of inser- 
tion. On the third day after the operation we first begin to perceive the 
specific efifects of the virus, in the shape of a small, hardened point at the 
seat of the wound, surrounded by a faint, erythematous redness. Over 
this hardened point, which grows gradually larger, the cuticle is elevated 
on the fifth day into a vesicle, by a thin, transparent, and pearl-colored 
serous exudation. This vesicle soon becomes umbilicated, so that by the 
following day, the sixth, the depression in the centre, constituting the um- 
bilicated character, is generally perfectly manifest, and at the same time 
the vesicle is surrounded by a very narrow ring of inflammation. The 
vesicle continues to increase in size, until on the eighth or ninth day it 
has reached its highest degree of development. At this stage the vesicle 
or pock is large, usually about one-third of an inch in diameter, and it 
projects very considerably above the general surface. Its shape is circu- 
lar, as a general rule, though not unfrequently it is oval, this depending 
apparently upon the mode in which the puncture has been made. The 
color of the pock is dull white or pearly, or sometimes it has a yellowish 
tint. The quantity of fluid contained in the cavity of the vesicle differs, 
of course, according to its size. The structure of the pock is found, upon 
careful examination at this time, to be cellular, the number of cells 
amounting commonly to eight or ten ; very often there is a small, dark- 
colored scab on the very centre of the vesicle, even at this period, though 
in other instances this is absent, the surface of the vesicle being formed 
exclusively of thin and transparent cuticle. The scab just alluded to has 
seemed to us to consist of the little incrustation, formed at the point where 
we had introduced the virus by the drying up of the minute quantity of 
blood escaping after the puncture, and of the dissolved virus which had 
not been absorbed. We have often noticed that when the small scab just 
alluded to has been rubbed off* the arm on the second day, the vesicle has 
presented no scab as early as the eighth day. On the eighth day the 



SYMPTOMS — COURSE. 811 

little ring of redness at the base of the pock, which has hitherto been very 
small and narrow, begins to enlarge so as to form the areola. This in- 
creases during the ninth and tenth days, forming a brilliant scarlet or 
dark-red inflammatory circle of about two inches in diameter, and consti- 
tuting one of the most strongly marked fiealures of the vaccine <lisease. 
The color of the ring is most intense at the edge of the vesicle, and then 
fades gradually to its outermost boundary. On the ninth and tenth days, 
in connection with the areola, the skin and cellular tissue on which the 
vesicle is seated, and that for a short distance beyond the margin of the 
latter, become hardened and tumefied, forming a solid knot or lump in 
the derm, like the base of a furunculus. The inflammation which causes 
the areola is often so intense as to occasion the production of vesicles, 
which are almost always discoverable with the aid of a lens, and are 
sometimes distinctly visible to the naked eye. On the tenth day the dis- 
ease is usually at its height, and it is then, of course, that all its peculiar 
characteristics are most strongly marked. At this time tlie child, when 
of an age to describe its sensations, will often complain of heat, itching, 
and pain in the inflamed spot; the arm is heavy and not willingly moved, 
or it is moved with care and caution ; there is, in a good many instances, 
some irritation and swelling of the axillary glands, and very frequently a 
decided febrile reaction may be noticed. In other cases, on the contrary, 
none of these symptoms will be present. The child is gay and cheerful, 
its movements free, quick, and unembarrassed, and it seems in all respects 
to be in its ordinary condition of health. 

From the tenth day the disease begins to subside. The areola fades so 
as to have nearly disappeared by the fourteenth day ; the fluid contained 
in the vesicle is gradually converted into pus, and the cellular structure of 
the pock is broken down so as to form, by the thirteenth day, but a single 
cavity, in which the pus is contained ; the process of desiccation is going 
on rapidly during this time, so that about the fourteenth day the vesicle 
has disappeared, and in its place there is a firm, hard scab, of the shape 
and size of the vesicle. This scab continues to harden for some days 
longer, and at the same time contracts somewhat in size and grows darker 
in color, until at last it is of a very dark brown or mahogany tint. It 
separates gradually from the tissues beneath, the separation beginning at 
the circumference, and falls off* usually about the eighteenth or twenty- 
first day, leaving beneath a small ulcer, which soon heals, or else a cicatrix 
of the shape and size of the pock. The cicatrix is at first of a deep red 
or purple color, but fades gradually, until it becomes much whiter than 
the surrounding skin. The scar left by the vaccine disease is very charac- 
teristic, and is often, though not by any means invariably, indelible. To 
be at all depended on as a mark of the disease, the scar should be small, 
circular, of a smooth and somewhat shining appearance, and it should 
exhibit radiations and little depressions or pits. The depressions are sup- 
posed to have been caused by the cells constituting the pock in its early 
period. 

There Is rarely more than a very slight constitutional disturbance at- 
tendant upon the course of this disease. About the eighth day, a decided 



812 VACCINE DISEASE. 

febrile reaction, attended with some unusual warmth of the surface, rest- 
lessness at night, and fretfulness of the temper, is often observed. In a 
few instances we have noticed distinct disturbance of the health about the 
third and fourth days ; amounting only, however, to unusual irritability 
and discomfort through the day, and to wakefulness or disturbed sleep at 
night. 

Irregularities and Anomalies. — We have now described the regu- 
lar course of a vaccination — that which it pursues in a large majority of 
the cases. Certain variations from the above standard or typical course 
are frequently, however, met with, and require some notice. These varia- 
tions may consist merely in the degree of severity of the local and general 
symptoms, or in the appearances presented by the pock, without affecting 
at all the validity of the disease ; or they may concern the duration of the 
phenomena ; or, lastly, they may be such as to call in question the validity 
of the disease, leaving us in some doubt as to whether it has protected the 
constitution against variolous attacks or not. 

The severity of the local inflammation occasioned by the vaccination, 
and that of the general symptoms also, varies often to a considerable ex- 
tent. In some instances, and especially when the virus employed has been 
procured recently from the cow, the specific inflammation proves very 
severe. We have seen the arm intensely red, and very considerably 
swelled, from the shoulder to an inch below the elbow, while at the same 
time the axillary glands were tumefied and tender, and the child very 
feverish and uncomfortable. This happened in three children, in all of 
whom we had employed the same virus; which, as we afterwards learned 
of the person from whom w^e obtained it, had been taken quite recently 
from the cow. It produced the same violent inflammation, moreover, in 
several other subjects in whom it was employed. This, however, is not 
to be regarded as by any means a usual occurrence when bovine virus 
has been employed, since now that we very frequently vaccinate with 
lymph directly from the cow, it is rarely that we observe any severe in- 
flammation. 

If the vesicle happens to be broken by accident soon after its forma- 
tion, its appearances during the subsequent progress of the disorder will 
often be very different from those exhibited in subjects in whom no such 
accident occurs. The vesicle loses a portion of its contents; it becomes 
conoidal and irregular in shape, instead of being circular and umbilicated ; 
it does not exhibit the pearly white and diaphanous color which belongs 
to it, but is yellowish and opaque; the areola is often premature and 
irregular in shape, and the scab is frequently small, uneven on the edges, 
and falls off at an unusually early period. 

Occasionally there is observed in the course of cow-pox a papular erup- 
tion over the body of the child. This occurs usually between the ninth 
and twelfth days. 

It is quite common for the disease to be retarded in its progress. The 
delay generally takes place in the appearance of the vesicle, this not show- 
ing itself until the sixth or eighth day, or, in some rare instances, not until 
the sixteenth, or even the twentieth, or forty-sixth day. The longest re- 



DIAGNOSIS. 813 

tardatiow that we have met with has been seven days. In this kind of 
retardation, the disease usually runs through its regular and natural phases 
after the vesicle has once made its appearance. In another kind of re- 
tardation the delay occurs iu the vesicular and pustular stages of the 
affection, the papule appearing at the ordinary time, but the disease not 
reaching its height or maturity until the eleventh or twelfth day. 

The forms of variation from the ordinary course of cow-pox just de- 
scribed, do not seem to be connected with any diminution iu the protective 
power of the disease. 

It sometimes hap|x^ns that the operation of vaccination gives rise to a 
disease totally unlike the true vaccine disease, one which does not protect 
against small-pox, and which has therefore been called furious vaccine 
disease. 

It was formerly the custom to describe quite a variety of appearances 
as indicating with greater or less probability a spurious disease. Of late 
years, however, it is generally admitted that the spurious pock is of much 
less frequent occurrence than was at one time supposed, and that, when it 
does occur, its characters are so marked as to make it easy of recognition. 
In tact, it happens in a very large majority of cases, that the vaccination 
either fails entirely, the puncture being productive of no other results than 
those which would naturally flow from a slight wound of the skin, or else 
that it is followed by a true and easily recognized vaccine pock. 

When, however, the operation is followed immediately or within a day 
or two days by inflammation, and the appearance of a pustule, without 
the previous production of a vesicle ; when this pustule is irregular iu 
shape, yellow in color, acuminated, easily broken, and terminatiug in a 
soft, yellowish, ragged-looking crust, which falls ofl upon the fifth, sixth, 
or seventh day, there is assuredly reason enough to call the vaccination 
spurious, and it becomes the imperative duty of the practitioner to regard 
it as such until subsequent and repeated trials with other and fresh virus, 
have proved the child to be protected. 

Diagnosis. — There can be no difficulty whatever in distinguishing the 
vaccine di.sease when it occurs in its regular form. The successive phases 
through which the eruption passes, and the particular appearances which 
it presents in each stage, are so unlike all other diseases, except, indeed, 
smallpox, as to render it very easy of recognition. 

•Sometimes, however, there is a little difficulty in determining whether 
the eruption is spurious or regular. But this rarely happens except under 
circumstances in which we should ex|>ect some modification in the phe- 
nomena of the disease, to wit, when its course is interfered with by the 
efl^ecta of a previous vaccination, or of an attack of variola. The irregu- 
larities arising from these causes are such as might he anticipated, and 
will be described in the article on revaccination. Whenever, however, the 
disease fails, in any imfK)rtant r(*spect, to exhibit the perfect attributes of 
a well-marked p<ick, both as regards its time of development, its changes, 
and its particular appearances at each stage, in a child not previously vac- 
cinated, nor having had small-pox, the only wise and prudent plan to 



814 VACCINE DISEASE. 

follow is to repeat the operation a few weeks after the doubtful &ne, so as 
to test thereby the protective power of the first. 

Protective Powers. — Though vaccination in infancy has not proved a 
sovereign protection against small-pox, as was at first hoped and expected, 
the security it does atford, when properly used, against one of the most 
loathsome and dangerous of diseases, is so nearly perfect that the thought 
of its benevolent power ought to rouse every feeling of thankfulness of 
which the human heart is capable. It has come to pass within a few years, 
here and there in the world, and we know this was the case in Philadelphia, 
that some persons have begun to question the real value of vaccination. 
Such persons always seemed to us the most crotchety and foolish of man- 
kind, and since small-pox exhibited its powers here, as it did in the epi- 
demic of 1871-2, we imagine those very persons are quite ready once again 
to thank Providence for its great boon, and to do true homage to the great 
discoverers of vaccination. 

As to the protective powers of vaccination, we have had proof abun- 
dant, in our own experience alone, to satisfy us that this is complete when 
it is properly applied. We have never seen life lost or the face disfigured, 
during thirty-two years of experience, in any one who had been well vac- 
cinated in infancy, and then successfully revaccinated at puberty. We had 
never seen a fatal case of small-pox in a subject under 43 years of age, 
who had been well vaccinated in infancy, until the late epidemic, though 
we had seen two who had it severely enough to pock-mark them. We 
knew that such cases occurred, but none had occurred in our own practice; 
and our experience in the late terrible epidemic has but confirmed our faith 
in the powers of vaccination. During its prevalence we saw no severe nor 
dangerous varioloid or variola in children under 10 and 12 years of age. 
It was not except among those over 15 and 20 years of age that we began 
to see and hear of dangerous cases of the disease ; and after successful re- 
vaccination, even in those most exposed, we saw not a case even of vario- 
loid, much less of severe variola. We could, had we the space, cite par- 
ticular instances in our own practice in proof of the absolute protection 
aflforded by re vaccination, but deem it best to give some facts illustrative 
of this power from the hospital experiences of the late epidemic. 

In the report made to the Board of Health, of this city, by Dr. Welch, 
of the Municipal Hospital, during the epidemic of 1871-2, are some facts 
which show most strikingly the power of vaccination. At page 9 are given 
the following cases : 

"Case 1. Child, aged two years; vaccinated in infancy; two good cica- 
trices ; came in with mother, who had small-pox ; sixteen days in hospital ; 
no disease. 

"No. VI. Infant, setat. 10 months; not vaccinated; admitted Febru- 
ary 10th, along with its mother, who had varioloid, and from whose 
breast it was nursing ; vaccinated same day. February 16th. — Two con- 
vulsions. 17th. — Perfectly well again ; vaccination taking well ; fourteen 
(14) days in hospital ; no disease. (This child returned to the hospital 
with measles.) 



PROTECTIVE POWERS. 815 

" Xo. IX. Child, aM. 7 years ; vaccinated six months ago ; fair cicatrix ; 
eleven (Hi days in hospital ; no disease. 

"No. X. Chilli, an. 8 years; vaccinated six months ago; fair cicatrix ; 
eleven (11) days in hospital ; no disease." 

At page 12 Dr. Welch states another very interesting fact, ^viiich coin- 
cides with the experience of the London Sinall-pox Hospital. He says: 
"In this connection we might add that the physician in charge, his two as- 
sistants, the matron — who has been connected with the hospital for twenty- 
four years — the chief male nurse, and a number of others employed at the 
hosi)iial during the epidemic, were protected only by vaccination and re- 
vaccination. Indeed, not a single person connected with the hospital, who 
had been revaccinated, contracted the disease; while on the other hand, 
some three or four of the nurses, who had been affected by small-pox pre- 
viously, took the disease a second time." 

How any one can read such facts as these, and they might be indefinitely 
increased, and yet refuse a child the boon of vaccination, is beyond our 
comprehension. 

In the last edition of this work we endeavored to show the necessity and 
propriety of revaccination. Hereafter we shall advocate revacciuation 
in all cases, no matter how perfect the first vaccination may be stated to 
have been, or how perfect the cicatrix or cicatrices. At the age of fif- 
teen, or as soon afterwards as possible, all young persons ought to be revac- 
cinated. There should be no waiting for an epidemic or for direct exposure 
to infection. The operation ought to be performed as regularly as the pri- 
mary vaccination. 

There is now a host of evidence on this point, but that which is given 
by Dr. Welch, in the report just quoted, of facts demonstrated by the late 
epidemic in this city will be all-sufficient. 

'* With reference to the practical efficacy of revaccination," he says, 
"the hospital record shows as follows: Among 2377 cases of small -pox 
admitted during the epidemic, only 3G are said to have been revaccinated, 
of which 4 died. But by subjecting these cases to a careful analysis, we 
find as follows ; Seventeen (17; were revaccinated at a distant period, some 
a.« far back as thirty-one (31) years; five (5) had not been revaccinated 
until after exposure; seven (7) were said to have been successfully revac- 
cinated, but were unable to exhibit any cicatrices as the result; sixteen 
(16) bore upon their arms very poor and uncharacteristic scars, some of 
which, indeed, were scarcely visible ; five (5) presented fair cicatrices ; and 
only three (3) were able to show gowl cicatrices. 

'M>f the four (4) who died, two (2) occurred among tho.se without cica- 
trices, one among tho.se revaccinated after exposure, and one among those 
showing p<K)r and uncharacteristic scars. 

"All the cases which bore upon their arms unmistakable evidence of 
successful revaccination, suffered from the mildest form possil)lc of the dis- 
ease. Indeed, three (3) of these cases exhibited an eruption of doui)tful 
character, and have therefore been recorded as ca.sesof varioloid (?). The 
eruption on three (3) others did not advance beyond the papular stage, 
and on seven (7) it was barely vesicular." 



816 VACCINE DISEASE. 

It is unnecessary to add anything more as to the protective power of the 
vaccine disease against small-pox. Those who are not convinced by such 
facts as these, would not believe one though he rose from the dead. 

Period of Performance. — The period usually chosen for the perform- 
ance of this operation, is soon after the age of three months. If, however, 
the infant be exposed to the contagion of variola, it is necessary to per- 
form it immediately, even upon the first day of life ; and in such cases the 
protective power is as perfect, and the local or constitutional irritation 
little greater, than when the operation has been deferred to the usual time. 

Susceptibility to the Disease. — The susceptibility to the vaccine 
disease varies greatly in different persons and different families, and is 
modified to a greater or less extent by the existence of other diseases in the 
individual at the moment of the operation. In some it is said never to be 
received, no matter how frequently or how carefully the virus may be in- 
serted. In others it is received with difficulty, requiring several repeti- 
tions of the operation before it can be made to take ; whilst in yet another 
class of subjects, the smallest amount of virus, when inserted in a careless 
and imperfect manner even, will produce the disease with the greatest cer- 
tainty. Nevertheless a large majority of children take the disease after a 
single operation, if this be performed with ordinary care and nicety. No 
explanation of the difiTerent susceptibilities of individuals to the disease can 
be given. The same difference is known to exist in regard to other conta- 
gious and even epidemic diseases, as measles, scarlatina, pertussis, variola 
itself, typhoid fever, and cholera. 

The susceptibility varies also in the same person at different times, with- 
out its being possible to ascribe this fact to any evident cause, since the 
child may appear on both occasions to be in the same condition as to health 
and other circumstances likely to influence its susceptibility to the conta- 
gion. Thus, we knew a child a few months old to be vaccinated four 
times, twice by the late Dr. C. D. Meigs and twice by one of ourselves, 
each operation following rapidly the preceding one, without success, though 
the virus was known to be good from its having succeeded in other sub- 
jects, and though it was changed each time. The child appeared to be in 
perfect health. There was no eruption of any kind upon its surface, nor 
any other condition that could explain its insusceptibility. After the 
fourth operation, the attempt was suspended for about four months, then 
renewed, and with instant and entire success. In another case, the vary- 
ing susceptibility of the same individual to the disease was still more strik- 
ingly exemplified. An infant, a few mouths old, was vaccinated four 
times in succession from the scab without success. It was then vaccinated 
with fresh lymph taken from the arm of an infant who was undergoing the 
disease. This also failed. A few weeks after this, the operation was again 
performed with the dried scab, and this time with perfect success. This 
same experience has more recently occurred to us in a case where vaccina- 
tion was performed four times at short intervals with fresh bovine virus 
without success, but on a fifth attempt complete success was obtained. 

Certain eruptions existing previously upon the surface, have seemed to 
us to prevent the reception of a vaccination. The eczematous and impeti^ 



SYPniLITIC INOCULATION. 817 

ginous diseases of infancy and childhood have certainly had this effect in 
our experience, though M. Taupin {Diet, de Mcdccine, t. xxx, p. 400) is of 
the contrary oi)iuiou ; he having found that the disease has been merely 
retarded when the operation was pertbrmed during the initial stage of the 
eruptive fevers, whilst its course was suspended even entirely when any of 
these affections occurred in a child already vaccinated, to be resumed again 
after the cure of the eruptive fever. 

There is another circumstance concerning the supposed effects of other 
diseases on the vaccine affection, to which it will be well to draw attention. 
We are sure there are few practitioners, having any considerable amount 
of business, but must have been annoyed, and injured perhaps in tlieir 
reputations, by the notion so prevalent in the community that vaccination 
may impart to children other diseases. This prejudice exists particularly 
in regjird to the chronic cutaneous eruptions of infancy and childhood, so 
that we have frequently had parents to insist to us that the impetiginous 
or eczematous disease under which their child might be laboring, has been 
caused by the vaccination, performed perhaps recently, or even months 
before. M. Taupin, quoted by MM. Guersant and Blache (Diet, de Med., 
t. xxx, p. 414), vaccinated a large number of children at the Children's 
Hospital in Paris, with virus taken from subjects affected with itch, scar- 
latina, measles, varicella, varioloid and variola, rachitis, scrofula, tubercu- 
losis, chronic eruptions of the scalp, dartres, etc., without communicating. 
to the patient any of these affections, either those of acknowledged conta- 
gious or non-contagious nature. A very curious case illustrative of this 
point is mentioned by Dr. Gregory in his Lectures on the Eruptive Fevers 
(Am. ed.. New York, p. 270}. " A child, who had been exposed to the 
infection of small-pox, was vaccinated. Both diseases advanced. A 
lancet charged with lymph from the vaccine vesicle produced cow-pox. 
Another lancet charged with matter from a variolous pustule, /ormct/ within 
the vaccine areo/a, communicated sraall-pox." We mention the result of 
these ex|)eriments in order to show how little foundation there is for the 
popular notion above alluded to, and to give to the practitioner an argu- 
ment with which to defend himself against the unjust accusations of those 
who may assert his vaccination to have been the cause of any disorder 
that may have followed upon it. Not that we would ourselves employ 
virus taken from a child suffering from disease of any kind whatsoever, 
since this is, to say the least, unnecessary, and ought to be avoided. 
Indeed, we have never employed a vaccine crust taken from a child who 
was not apparently in perlect health. The smallest amount of cutaneous 
eruption upon a child has always been sufhcient reason with us to reject. 
the virus afforded by such a patient, and as this mwd be the safest plan to 
adopt, it is of course the proiHjr one. 

The still more serious charge has, of recent years, been made against 
vaccination, that it may be the means of transmitting constitutional 
gyphilw. And there are well-authenticated cai*es in which the operation 
has undoubtedly been followed by this terrible result. In every instance, 
however, .«o far as we are aware, in which the exact mcKle of the vaccina- 
tion could be ascertained, it has been found either that the child from 

62 



818 VACCINE DISEASE. 

whom the virus was obtained, presented at the time evidences of constitu- 
tional syphilis, or that the virus had been impure, being mixed with blood 
or pus, which may have been the medium of infection. There is, indeed, 
no evidence whatever to show that the lymph or crust derived from a 
typical vaccine eruption, in an apparently healthy child, can possibly be 
the means of transmitting any constitutional disease. It is more prudent, 
however, that if the lymph be used, it should not be taken after the eighth 
day of the existence of the vesicles ; and that in obtaining it, all haemor- 
rhage should be avoided. 

Mr. Jonathan Hutchinson {Med.-Chirurg. Transactions, for 1871) gives 
two series of cases which show the possibility of communicating syphilis 
by means of vaccination. At page 322 he states his belief that the blood 
is the source of the contamination. He says : " There can, I think, be 
little doubt that in this instance it was the blood, and not the vaccine 
lymph, which was the source of contamination." At page 325 he quotes, 
from a previous report, the following, amongst other conclusions : " That 
the blood of a child suffering from inherited syphilis can, if inoculated, 
transmit the disease with great certainty. 

" That it is quite possible for vaccine lymph and blood to be transferred 
at the same time, and for each to produce its specific results, the effects of 
the syphilitic inoculation occurring subsequently to those of vaccination. 

" That it is quite possible to vaccinate successfully from a syphilitic in- 
fant in the stage of the utmost potency as regards its blood, without com- 
municating syphilis." 

In regard to this most important point we have two statements to make : 
.that we have never had occasion to suspect even that we have been the un- 
fortunate instruments in communicating this disease in our own practice, 
and that we have always used the dried scab. Is this happy exemption 
from such an accident the result of care in selecting the virus, or does it 
depend on our constant use of the dried scab ? Is not the danger of having 
blood intermixed with the lymph much greater, when the vesicle is opened 
by the surgeon on the eighth day, than when the lymph is left to dry and 
form a scab in the natural mode ? 

Still as the danger of communicating syphilis by badly selected vaccine 
virus does exist, it is important to be aware that recently there has been 
introduced into the American market a supply of lymph directly taken 
from the cow. This is furnished in the form of quill slips, one end of 
which is charged with the lymph ; and they can be constantly obtained 
fresh in our larger cities, as the supply is replenished every day or two. 
Whenever it is not possible to obtain perfectly satisfactory humanized 
virus, either lymph or crust, the bovine virus above mentioned should in- 
variably be used. Indeed, of late we have been more and more in the 
habit of employing it on account of its convenience and reliability. The 
more severe local inflammations which was formerly thought to attend the 
use of lymph directly or only a few removes from the cow, is not found to 
follow the employment of these slips to any objectionable degree. 

Operation. — Under this head we shall consider several important 
points : the relative value of the dried scab and fresh lymph ; the question 



OPERATION. 819 

as to whether it is best to raise more than one vesicle by more than one in- 
sertion of the virus ; and the various modes of performing the operation. 

In this city it has been the custom for many years past to use the dried 
scab, and to raise, as a rule, but one vesicle. After an experience, ex- 
tending, in the case of one of us, over thirty-two years, during which we 
have never used anything, but the crust, and have rarely made more than 
one insertion, we can aver that we have never known auy one to die of 
small-pox who had been successfully vaccinated and then successfully re- 
vaccinated by this method. We have seen a good many mild varioloids, 
in subjects that had not been revaccinated, from the ages of twelve and 
fifteen upwards, but only in two cases have we known the disease to be 
severe enough to pock-mark the patient. We know of but one death from 
small-pox in our own circle of patients. This occurred in a gentleman 43 
years of age, who was originally vaccinated by the late Dr. C. D. ]\[eigs, 
and who was never revaccinated until four or five days after he had been 
exposed directly to the small-pox infection. The operation came too late. 
Though the puncture took, he died of hemorrhagic small-pox of a virulent 
form. 

In using the crust we have always taken great care to select only those 
from the most healthy children. Any blemish upon the skin, any shadow 
of doubt as to the perfection of the vaccine disease, ought always to cause 
the rejection of the crust. 

The scab is less certain to take the first time than the fresh lymph, but 
it can always be made to take by perseverance, and we confess that it ia 
hard for us to understand why the vaccine disease, if it be perfect in all its 
stages and phenomena, is not as much a vaccine disease when it springs 
from the crust as when it proceeds from fresh lymph, and therefore as com- 
petent to aflTect the economy through which it passes according to its natural 
law. 

If the crust is to be used, it ought to be as fresh as possible, to insure its 
taking at the first operation. When the physician is obliged to keep it for 
several weeks, he should preserve it in some close receptacle, as between 
glasses, in tin-foil, oiled paper, between two pieces of wax, or in hermetically 
closed glass vials. 

If the fresh lymph is preferred, the children to be vaccinated should be 
collected together about the vaccinifer (the child from whom it is to be 
taken) on the eighth day of the disease. The vesicle must be very care- 
fully opened, so as to avoid wounding the true derm, and thereby causing 
any effusion of blood, and the lymph conveyed on a lancet directly from 
arm to arm. 

It is proper to say that this is the mode of vaccinating usually preferred 
in Europe as the most certain and successful. 

Though we have stated that, in our own practice in this city, one thor- 
oughly characteristic vesicle at the primary vaccination, and one again at 
the revaccination, has been entirely successful in securing complete protec- 
tion against small-pox, the opinion is held abroad that more than one ves- 
icle gives greater security, in the event of «mall-p<»x attacking the vacci- 
nated, than a single one. This opinion, which is baseil upon very numerous 



820 VACCINE DISEASE. 

observations in England and Germany, is so strong and positive that we 
think it best to advise herafter that at least two insertions, so as to raise 
two vesicles, shall be made in this country. Any one who wishes to study 
this question may refer to an excellent article on Vaccination, by Dr. 
Edward Cator Seaton, in Reynolds's System of Medicine, vol. i, page 483, 
where the whole subject is fully discussed. At page 499 Dr. Seaton insists 
that it is the duty of the physician to produce four or five genuine good- 
sized vesicles.^ 

It is proper to put before the reader this opinion of so able an authority 
as Dr. Seaton, so that any one who feels bound by such authority may fol- 
low his rule. For ourselves, we can only repeat that thus far in our own 
experience, one thoroughly good primary vaccination, and a second char- 
acteristic vesicle obtained at the revaccination, have been entirely successful 
and sufficient. In obedience, however, to th'e facts collected in England 
and Germany, we shall, hereafter, as stated above, advise the raising of at 
least two good vesicles at each vaccination. It makes but little difference 
whether the two be raised on one arm, or one on each. For the convenience 
of handling the child, we think it will be best to make the two insertions 
on one arm. 

We think it the duty of the physician who vaccinates a child always to 
see to it himself that the result is a perfect vaccine disease. This matter 
is too important to be trusted to any inexperienced person. The physician 
has not done his duty who trusts to anything but his own eye as to the 
genuineness of the vesicle which results from his operation. He should 
examine it himself on the eighth or ninth day of the disease. The special 
characters of the disease have already been fully described. 

It would be well, too, that physicians in charge of families should ex- 
amine the cicatrices which follow vaccination, and if they fail to present 
the characters which belong to successful operations, he ought to repeat 
the vaccination. Dr. Welch, whose experience in this matter was large, 

1 The protective power of vaccination, as well as the influence exerted by the 
perfection and the number of the insertions, as shown by the cicatrices, is remark- 
ablj' well exhibited in the following table quoted by Dr. Seaton (Art. Vaccination, 
in Reynolds's Syst. of Med., vol. i, p. 499), from Mr. Marson. The table is based 
upon 15,000 cases. Of these it was found that the unvaccinated died at the rate of 
37 per cent., and the vaccinated at the rate of only 62 per cent. 

Classification of Patients Number of Deaths per cent, 

affected with Small-pox. in each class respectively. 

1. Unvaccinated, 37. 

2. Stated to have been vaccinated, but having no cicatrix, . . 23.57 

3. Vaccinated. 

a. Having one vaccine cicatrix, . . , . . 7.73 

b. Having two vaccine cicatrices, . . . . .4.70 

c. Having three " " ..... 1.95 

d. Having four or more vaccine cicatrices, . . . 0.55 



«t. Having well-marked cicatrices, 
^. Having badly-marked " 
4. Having previously had small-pox, . 



2.52 
8.82 
'19. 



REVACCINATION. 821 

says that a good cicatrix is cue "with a well-defined margin, slightly ex- 
cavated, and reticulated or honeycombed." What he classifies as a fisiir 
cicatrix presents the same characteristics, but to a less marked degree, 
and poor ones are those "pointed out as the result of vaccination, but 
which are so indistinct or uncharacteristic as to make it diflRcult. and some- 
times even impossible, to recognize them as vaccine scars." In case any 
practitioner should meet with the latter in a family he may be attending, 
he ought, we think, to urge upon the parents the necessity of repeating the 
operation at once. 

REVACCiyATiox. — We think few physicians or laymen who watched the 
violent epidemic of small-pox which prevailed in this city during 1871 and 
1872, can doubt as to the necessity of revaccination. So convinced are 
we by what we saw during that epidemic of this necessity, that we shall 
hereafter advocate the repetition of the operation at the age of puberty 
as a matter of domestic habit and law, a matter to be attended to by the 
heads of families with the same regularity and care that is now universally 
bestowed by all educated and careful people upon the vaccination of infants. 
Each child of a family ought to be subjected to this operation at or about 
the age of fifteen, and we think the family physician ought to bestow the 
same care upon this as upon the primary vaccination. One trial, without 
result, we hold to be of no more use than it would be in an unvaccinated 
child. The trial should be made again and again until a result is obtained. 
We have ourselves of late years repeated it twice, three times, and, in one 
instance, seven times, before we succeeded in obtaining a vesicle. Once 
the vesicle obtained, with a good areola, we believe the subject is safe for 
many years, probably for the lifetime. 

The characters of the vaccine disease produced by a revaccination are 
not always the same as those obtained at the primary vaccination, especi- 
ally when the time between the two operations is only that extending from 
birth to puberty. We have seen at later periods of life, at thirty and forty 
years of age, for instance, as perfect specimens of the vaccine disease from 
a secondary vaccination as we have ever seen in the infant. Not a feature 
has been wanting. The exact phases of the disease, the papule, the vesicle, 
the precise duration as to time, the areola, the constitutional disturbance, 
and the rpsulting cicatrix, have all been perfect in every point. 

It is difficult to escape the conviction, that in such cases as these just 
mentioned the protective power of the primary vaccination had been en- 
tirely obliterated, and such, indeed, is and has been the opinion of many. 
A careful observation has shown, however, that this is not correct, and 
that, to use the words of Dr. Seatou {loc. cit., p. oil ), we cannot " draw 
from the local phenomena of revaccination any inferences whatever as to 
the state in which the revaccinated person was as to liability to small-pox. 
Jenner himself, indeed, pointed this out in his first treatise, and showed 
that the natural cow-pox might be induced again and again in persons 
who, being protected against variola by their first attack of cow-pox, could 
not be variolated either by inoculation or by exposure, as well as that cow- 
pox might be made to take on those who had had small-pox." A table, 
given by Dr. Sealon to show the results of revaccination in the Wiirtem- 



822 VACCINE DISEASE. 

burg army in 1831-35, and in the English army in 1861, shows conclu- 
sively that revaccination was nearly as successful in producing a perfect 
vaccine disease in those who bore the marks of previous small-pox, and in 
those who had good cicatrices of previous vaccinations, as in those who 
bore no marks of previous vaccination or small-pox. 

These facts overthrow the prevalent notion held by the public at large 
and by many physicians, that a successful revaccination is a sure sign that 
the subject had lost the protection afforded by the previous vaccination. 
They also overthrow the idea that it is necessary to revaccinate every few 
years in order to renew the protective power of the vaccine disease. One 
good primary vaccination doubtless affords full protection throughout life 
in many, but it does not in all, and since it is impossible to determine 
which are the protected and which the unprotected, it is necessary to re- 
vaccinate all. But one successful revaccination is probably all that is 
required. Should, however, any one who has been thus successfully re- 
vaccinated be exposed directly to the infection of small-pox many years 
afterwards, it might be well to repeat' the operation once again. The 
fashion, however, of being revacciuated every few years, which some per- 
sons indulge in and some physicians assent to only too readily, is simply 
a work of foolish supererogation not unattended with risk, since vaccine 
punctures, though made in the most legitimate way, will occasionally 
cause severe and even dangerous sores. 

We have already said that revaccination at puberty rarely produces a 
vaccine disease of typical character. Still more is this true of children 
under puberty. At that early age the disease usually begins earlier after 
the puncture than in the primary form, reaches its height by the fifth or 
sixth day, and then declines. The vesicle is apt to be acuminated rather 
than umbilicated, the areola is irregular in outline, narrower, paler, and 
is usually hard. The scab is small and imperfect, looking more like one 
formed by the desiccation of pus than like that formed from true vaccine 
lymph, and it is often complete by the eighth day, and soon falls. There is 
often a good deal of constitutional irritation caused by revaccination, more 
even than in the primary disease, and there is also much local irritation 
in the form of itching and pain. Nevertheless, these appearances are in- 
valuable as showing that the lymph employed has affected the constitution 
of the patient. Without some such response to the revaccination, we hold 
the operation to have been useless, and always repeat it, as has already 
been stated. 

To impress upon all the power and value of revaccination, we will quote 
some facts given by Dr. Seaton {loc. eit, p. 509) : " Heine found that in 
five years there occurred among 14,384 revacciuated soldiers in Wiirtem- 
burg only one instance of varioloid, and in 30,000 revacciuated persons in 
civil practice only two cases of varioloid, though during these years small- 
pox had prevailed in 344 localities, producing 1674 cases of modified and 
unmodified small-pox among the not revacciuated, and in part not vac- 
cinated, population of 363,298 persons in those places in which it had 
prevailed. In the Prussian army, since the introduction of systematic 
revaccination of all, the annual deaths from small-pox (which at one time 



REVACCINATION. 823 

were 104) have not averaged more thau 2 ; and on analysis of 40 fatal 
cases that occurred in twenty years, it appeared that only 4 were in per- 
sons who were said to have been successtuliy revaccinated." 

He also cites Mr. Marsou's statement, to the effect tliat in " thirty years 
DO uui-se or servant at the Small-pox Hospital has taken small-pox, he 
having taken care always to revaccinate them on their coming io live in 
the hospital ; and further, that when a large number of work-people were 
employed for several mouths about the hospital, most of whom consented 
to be revaccinated, two only were attacked by small-pox, but they were 
amongst the few who were dot revaccinated." 

With a few words on the mode of performing the operation of vaccina- 
tion, we shall bring this article to a close. 

Different methods of inserting the vaccine virus have been employed 
by different practitioners. The two methods most frequently resorted to 
are those by incision and puncture. The former consists in making a 
superficial incision of several lines in length into the skin, in such a way 
as to cause a ver}' slight effusion of blood. Into this is introduced a small 
quantity of a dried vaccine scab reduced to a fine powder, or a piece of fine 
thread wet with the vaccine fluid, or with water holding in suspension a 
portion of dried virus. Over the wound is then placed a piece of isinglass 
plaster, which is secured by a bandage. This is to be removed after two 
or three days, and the disease allowed to pursue its regular course. The 
operation by puncture is performed by introducing horizontally beneath 
the skin a needle or lancet charged with the virus, and theu withdrawing 
it in such a way as to leave the virus in the wound. Of these two modes 
the latter is the one now most frequently adopted, the former having been 
found to occasion, not unfrequently, a spurious disease, and to be of very 
difficult application in the cases of children. For our own j)art we have 
used for some years past a method that we have found much the most 
convenient in children, and which rarely fails when it is carefully per- 
formed. We take a common thumb lancet, which should not be too sharp. 
Holding the arm of the child with our left hand, and stretching the .skin 
between the forefinger and thumb, whilst the under part of the arm is 
grasped by the second finger placed beneath the first, we lay the lancet 
flat upon the skin, and using the point, remove, by a repeated and very 
gentle rubbing movement, the cuticle, until the surface of the derm is 
laid bare, so as to allow of a perceptible, and merely perceptible oozing of 
blood, or, in other words, .so as to expose a living surface. This surface 
should be about as large as a small-sized bird-shot, and it should not 
bleed, but merely .«how that the vascular part of the derm has been 
reached and slightly exposed. On this surface the vaccine fluid or dis- 
solved scab is to be placed in quantity sufficient to cover it, and the nurse 
sbould be told to leave the arm bare and untouched for twenty minutes, 
or until the applied fluid has dried into a little scab, when no further pre- 
cautions are necessary. This mode of operating may at first scorn tedious 
and painful. We can only say tiiat when performed gently and gradually, 
it causes so little pain that we have often practiced it upon sleeping chil- 
dren without waking them. 



824 VARICELLA. 

If the quills of fresh bovine lymph are used, an abrasion of the cuticle 
is made in the ordinary manner, and the end of the quill charged with 
lymph is very slightly moistened and then rubbed on the abraded spot 
until the virus is thoroughly removed. 

The place usually selected for the operation is, as every one knows, on 
the arm, close to the insertion of the deltoid muscle. This is the best 
place as a general rule, and particularly in girls, whose parents often ob- 
ject to having the insertion made below this, lest the scar should be vis- 
ible in after years, when the arm is uncovered. In boys we often select 
the radial edge of the forearm some two inches below the elbow, since in 
this place the pock is least apt to be injured in the act of dressing the 
child, or of lifting it about. 



ARTICLE X. 



VARICELLA. 



Definition ; Synonyms ; Forms. — Varicella is a contagious eruptive 
disease of benign nature, characterized by more or less numerous trans- 
parent vesicles following rapidly upon small red elevations. The eruption 
is usually preceded by slight initial symptoms lasting from one to two days, 
and it terminates by the desiccation of the vesicles about the fifth or eighth 
day after their appearance. 

It is known also in English by the names of chicken-pox, swine-pox, and 
crystalli. 

Several different forms of the disease have been described by different 
writers under the titles of lenticular, conoidal, and globular; but inasmuch 
as these varieties are of no real importance in practice, we shall merely ad- 
vert to them casually in our account of the eruption. 

Causes. — Varicella is propagated in two ways ; by contagion^ and by 
epidemic influence. That it is contagious there can be no doubt, since 
nearly all observers agree upon this point. In our own experience we 
have seldom known any child, who had not had the disorder previously, 
to escape it when once it has entered a household. It rarely attacks any 
but children. Its epidemic nature is shown by the fact that in some sea- 
sons it is scarcely seen, whilst in others it prevails extensively over large 
districts of country, and attacks many children in the great towns and 
cities of those districts. Varicella occurs only once in the same indi- 
vidual. 

Considerable discussion has taken place at various times as to the real 
nature of varicella, some asserting that the disorder is merely one of the 
varieties of modified small-pox, while others maintain as strenuously that 
it is an independent and specific disease. The weight of authority, how- 
ever, seems to be clearly in favor of the last-mentioned opinion, and we 
have no hesitation in avowing this to be the conclusion to which our own 



SYMPTOMS — COURSE — DtTRATION. 825 

readiuor and experience have brought us. When wo consider, indeed, that 
varicella is, unlike either variola or varioloid, incomniunicable by inoc- 
ulation,* that it attacks indifferently the vaccinatetl and unvaccinated, 
that its course is entirely unaffected by previous vaccination, and that the 
vaccine disease is readily taken, and passes through its regular phases 
after varicella, we do not see how we can refuse to believe that the latter 
is something entirely independent of small-pox, and therefore a distinct 
and peculiar malady. 

Symptoms; Course; Duration. — The eruption is usually, but not 
always preceded by prodromic symptoms. These seldom last more than 
one, or at most two days, and consist at the very beginning of slight chilli- 
ness, or of a chill even, which is followed by a more or less marked febrile 
reaction. In some instances there is vomiting, but this is rare, and when 
it does occur, slight. "When fever exists it is marked by headache, accel- 
erated pulse, slight warmth of the surface, pain in the back and limbs, 
languor, indisposition to play, some unusual irritability of temper, dimi- 
Dution or loss of appetite, and unusual thirst. These symptoms may be 
present, and yet in so mild a shape that the child shall show no disposition 
to abandon its ordinary habits of activity and play, while in other cases 
again, there are literally no initiatory symptoms whatever, and the appear- 
ance of the eruption is the first declaration of the presence of the malady. 
Even when constitutional symptoms are present, they usually disappear 
by the third day. 

The eruption appears in the form of small papular spots, of a deep red 
color, and irregularly circular shape, which generally show themselves 
first on the front and back of the trunk, and extend very soon to the fiice, 
and a little later, to the extremities. AVe have known a child to go to 
bed at night with slight headache and fever, and present a well-marked 
though not yet abundant varicellous rash upon the upper part of the 
trunk, and on the face, on the following morning. These papules exhibit, 
in the course of a very few hours, small vesicles in their centres ; indeed, 
according to some observers, the eruption is vesicular from the very begin- 
ning. On the second day the papules are in great measure converted into 
vesicles, which may be either small and acuminated, constituting the len- 
ticular form of the disease, or they may be larger and of a more globular 
shape, constituting the conoidal and globular or globose forms of Willan 

• St«iner of Prague (quoted in Medical and Surgical Reportor, July 17th, 1875, 
p. 57) has lately inoculated varicella in several caj«es, with the following results : 

1. The contents of varicella vesicles arc inoculable; of 10 cases of inoculation, 
8 were successful and 2 failed. 

2. After the successful inoculation of varicella, varicella and not variola or vari- 
oloid was invariably produced. 

3. The stage of inoculation in all the successful cases was eight days. 

4. In 4 cases there were no prodromes ; in 4 cases there were prodromes of four 
days' duration. ^^ 

Vaccination has no influence on the production of the exanthem ; of the 8 case« 
of successful inoculation, 5 had been vaccinated, 3 had not. 

VHricfUa does not protect against variola ; in one case a child died of confluent 
Variola fourteen days after convalescence from an attack of varicella. 



826 VARICELLA. 

and Bateman. We deem it unnecessary, as above stated, to describe dif- 
ferent varieties of varicella, since this is useless for any practical purposes, 
and because we constantly see upon the same subject vesicles of very dif- 
ferent shape and size. When fully completed, the vesicles are often of 
very considerable size — two or three lines in diameter ; they contain a 
transparent fluid, which is either entirely colorless or of a faint orange 
tint, and some of them are surrounded by a small ring of inflammation. 
On the third day, the eruption continues in nearly the same state as on 
the second, except that the fluid contained within the vesicles assumes a 
yellowish appearance, owing to its passage from the serous into the puru- 
lent condition. On the fourth day, the process of desiccation begins and 
goes on rapidly, the vesicles that have not been broken by accident, or torn 
by the fingers of the child in its efforts to appease the itching which they 
give rise to, assuming a shrivelled and shrunken appearance at their mar- 
gins. As this process goes on, the vesicles are gradually converted into 
light brownish scabs, so that by the sixth day they are nearly all dried up. 
The scabs are usually thin ; they dry from the circumference to the centre, 
and between the eighth and ninth days fall off, leaving behind faint red 
spots, not depressed below the general surface, and which soon disappear. 

The eruption is generally accompanied, as was stated above, by a sensa- 
tion of heat and itching in the vesicles, which causes the child to rub and 
scratch them in such a way as often to break those which he can reach, 
and thus prevent them from passing through the regular periods of matu- 
ration and desiccation. 

Diagnosis. — There is but one disease with which varicella could be con- 
founded, and that is variola in some of its shapes. With regular small- 
pox such a mistake could scarcely happen even to the inexperienced. 
With varioloid, on the contrary, there might be some diflliculty, and yet, 
if it is borne in mind that in varioloid the initiatory fever is much more 
severe, lasting three days instead of twelve or thirty-six hours, that the 
eruption appears first on the face and extends very slowly to the trunk and 
extremities, and that the conversion from the papular into the vesicular 
condition is much more gradual than in chicken-pox, we think no serious 
diflSculty can ever occur in making the distinction between the two affec- 
tions. 

Prognosis. — The prognosis is always favorable. The only real trouble 
that we have ever known to occur has been from catarrh or pneumonia 
contracted by imprudent exposure during the convalescence. 

Treatment. — In a large majority of the cases, varicella requires no 
treatment beyond attention to diet for the first two or three days, and the 
avoidance of cold during the convalescence. When the constitutional 
symptoms are marked, the fever and headache being considerable, a dose 
of some mild cathartic, a little sweet spirit of nitre in cold lemonade or 
orangeade, rest in bed, and one or two foot-baths, will be all that is neces- 
sary to reduce these symptoms and make the patient comfortable. 



I 



TYPHOID FEVER. 827 



ARTICLE XI. 



TYPHOID FEVER. 



It is only of late years that the frequent occurrence of typhoid fever in 
young chldren has been fully recognized by medical authors. From the 
date of the publication of the classical work of Louis on this disease, until 
the year 1839, it appears to have been the almost universal belief that it 
was an atfection limited to adult life ; and with the exception of a few 
brief and vague descriptions, which evidently referred to this disease, 
though other names were used to designate it, medical literature contained 
no account of typhoid fever as it occurs in childhood. In the latter part 
of 1839, however, Rilliet {Thciie de la Faculte, 1840; and Maladies des 
EnjanU, t. ii, pp. 663-739) and Taupin {Journal des Counaissauces Med.- 
Chirurgi4^alei>) published separate and independent memoirs on this sub- 
ject ; and since that time the occurrence of typhoid fever in children has 
been frequently observed and very carefully studied. 

The fact that it was so long overlooked, is undoubtedly to be explained, 
in great part, by certain peculiarities which the disease presents in chil- 
dren, which caused its real nature to be mistaken, and led to the applica- 
tion of other names. 

Of these names, that of infantile remittent fever was the most frequently 
used, and though this term was made to include a number of other dis- 
eases, and although remittent fever does occur in children, there can now 
be no doubt that a large proportion of the cases so styled, were in reality 
cases of typhoid fever. 

Causes. — Age. — Typhoid fever has been observed during the first year 
of life, but is rare under the age of two years. We have however met 
with well-marked instances of it at the age of eighteen or twenty months. 
It is comparatively frequent between the ages oi three and eight years, 
and it attains its maximum of frequency in childhood between the ages of 
eight and eleven years. 

Sex. — The statistics of most authorities show a preponderance, more or 
less marked, of cases occurring in boys. In some series of cases this dis- 
parity has been remarkable (three to one) ; but, notwithstanding, it is 
probable that in a very extensive series the difference would be compara- 
tively trifling. 

Contagion: Epidemic Influence. — If typhoid fever be at all contagious 
it is in the slightest degree. On the other hand, it is well known that the 
dejecta from patients with this disease possess the power of producing it 
in those who are exposed to their emanations, or who drink fluiil which 
have been allowed to become in any way tainted by them. The noxious 
vapors from foul sewers, drains or cesspool.** are also frequently the cause 
of typhoid fever. It is moreover subject both to epidemic and endemic 
influences in a marked degree ; and it is owing to the varying action of 



828 TYPHOID FEVER. 

these causes that it presents the wide variety, in type and severity, which 
will be described. 

Anatomical Appearances. — These are strictly analogous to those 
found in the adult. When death occurs early in the attack, the agminate 
■glands of the ileum are found swollen, prominent, injected; the alteration 
being most marked in those nearest to the ileo-coecal valve. Later, how- 
ever, these glands ulcerate, the softening beginning either on the surface, 
and extending mor^ and more deeply, or beginning in the deeper portion 
of the patch, so that the superficial la3^er may be thrown off* as a slough. 

These ulcers thus destroy the mucous membrane, and present the sub- 
mucous or muscular coats for their base ; or, in some instances, the ulcera- 
tive process may extend through the muscular and even though the peri- 
toneal coats. We have known the most violent general peritonitis to be 
excited early in an attack of typhoid fever, in a girl 4 years of age, by the 
simple extrusion of inflammation, without the occurrence of perforation. 

According to Rilliet (loe. cit.), however, these ulcers are more slow in 
forming, smaller, and less numerous and deep in children than in adults ; 
and, indeed, he believes that in not a few instances the swelling and in- 
flammation of the gland may undergo resolution without the occurrence of 
ulceration. 

Too much importance must not, however, be attached to this statement, 
since it appears to us evident that a few cases, at least, of typhus fever are 
included amongst those upon which his memoir is based. 

The solitary glands are, in the early stage of the disease, prominent, and 
may be distended with a serous or more thick and yellowish secretion, so 
as to resemble vesicles or even pustules. Later in the attack their mucous 
covering is destroyed, and small, round, or oval ulcers, with everted edges, 
remain. These ulcers are also most numerous in the lower part of the 
ileum, though in some cases they are met with quite abundantly in the 
large intestine. 

The mesenteric glands are enlarged, softened, and strongly injected, the 
change corresponding in intensity to that of the agminate glands in the 
ileum, and being most marked in those glands which are nearest the ileo- 
coecal valve. Usually the swelling of these glands subsides without sup- 
puration occurring, but occasionally this ensues, and the gland is converted 
into an abscess with thin walls. 

The cicatrization of the intestinal ulcers appears usually to occur rap- 
idly; thus, Rilliet has seen the process completed by the thirtieth day, 
though this is probably sooner than it is entirely finished in the majority 
of cases. 

Ulcers of other mucous surfaces, as of the pharynx and larynx, are 
more rarely met with in children than in adults. The spleen is nearly 
always considerably enlarged and softened. 

The blood in severe cases is dark and uncoagulable, and the lining 
membrane of the heart and large vessels is stained by imbibition. In 
some cases quite firm coagula are met with in the cavities of the heart. 

Even in cases where the most violent nervous symptoms have been 
present, the brain rarely presents any more positive lesion than mere con- 



SYMPTOMS. 829 

gestion of the vessels of its membranes 'and substance, with at times some 
subarachnoid ettusiou. Of course, in cases where death has resulted in 
cousequeuce of some complication, the lesions of the intercurrent disease 
will be found. 

Symptoms. — The general course of typhoid fever is much the same in 
children as in adults. 

It presents also the same wide variety in its type and degree of severity, 
depending upon the predominance and excessive development of some one 
of the elements of the disease ; and it would be easy, therefore, to divide 
the disease into a great number of forms, according to the prominence of 
each functional disturbance; but iis our object is merely to give a practi- 
cal description of the disease iis met with in children, we will, in consider- 
ing its course, give a brief sketch of an ordinary case, and then dwell in 
detail upon certain symptoms which require special notice, as presenting 
special peculiarities in childhood. 

In the majority of cases, the attack is preceded for some days by slight 
prodromes ; the child, who ordinarily may enjoy robust health, appears 
languid, and is easily tired, and indisposed to play ; he loses his appetite, 
is restless during sleep, and possibly may complain of colicky pain in the 
abdomen, perhaps attended with slight looseness of the bowels. After 
this state of vague indisposition has lasted from three or four to eight or 
ten days, more decided symptoms manifest themselves, and the attack may 
be said to fairly begin. 

More or less febrile action now appears ; but this is rarely continuous, 
and for the ensuing five or six days there are distinct and marked remis- 
sions, usually in the morning, but sometimes so marked and prolonged 
that it is only towards night that the skin becomes heated, the pulse fre- 
quent, and the child grows restless, while, during the day, he has merely 
appeared somewhat dull and languid. The loss of appetite continues, and 
becomes more complete, though thirst is marked ; vomiting is apt to follow 
eating, and is sometimes frequent and spontaneous ; the tongue presents a 
moist, whitish-yellow fur in the centre. The bowels either continue loose, 
or now become so for the first time ; the abdomen becomes somewhat large 
and tympanitic, and slight tenderness may be present in the righ't iliac 
region towards the close of the first week. 

The strength is rapidly lost, and the child, after the first few days sliows 
no desire to leave the bed. The respirations are somewhat hurried, and 
are aften accompanied by sonorous rales and slight dry cough. The pulse 
is accelerated, but rarely rises at this stage above 110. 

The expression grows dull and listless, unless temporarily excited during 
delirium, and the child takes but little notice of surrounding persons or 
objects. During the night there may even now In; a tendency to more 
marked cerebral disturbance, and the little patient grows very ri»stleae, 
utters sharp, shrill cries, or talks unmeaningly. 

About the end of the first week the characteristic eruption api>ears, first 
on the upper part of the abdomen, in the form of small, oval spota, scarcely, 
if at all, elevated above the surface, of a light rose color, disappearing on 
verj' slight pressure, and quite rapidly returning. 



830 TYPHOID FEVER. 

During the second week, the symptoms become more severe. The fever 
is more continuous, and the temperature ranges in different cases from 102° 
to 105°; it may still present, however, decided morning remissions, and it 
is not rare for profuse warm perspiration to occur, without having any 
critical value whatever. The pulse becomes more frequent, 120, 140, even 
160, and at the same time smaller and of less force. The respirations are 
also more hurried, and, when the pulmonary complication is marked, may 
be very rapid and shallow, and the cough frequent and annoying ; in such 
cases, auscultation reveals, especially over the postero-inferior part of the 
lungs, abundant mucous or subcrepitant rales. The vomiting ceases, and 
the child will usually take the liquid food offered it ; the tongue becomes 
more heavily furred, and may be dry and brownish in the centre, though 
it often remains moist and yellowish-white throughout. Thirst is apt to 
diminish, owing to dulness of the perceptions, but the child will frequently 
drink greedily of cold water if offered to it. The diarrhoea persists, how- 
ever, and the stools are ochre yellow and fluid ; the belly is more tympa- 
nitic, and may be extremely distended. The discharges, both of urine and 
fseces, are often involuntary, and the child does not even appear conscious 
of them. The urine is high-colored and scanty. The eruption continues 
and becomes more abundant, the spots which appeared passing away and 
being followed by successive crops. Sudamina are also frequently pres- 
ent especially when sweating occurs. The mind becomes more and more 
dull, though it is nearly always possible to rouse the child by speaking 
loudly to it ; delirium is usually present, especially in the night, and 
manifests itself in young children by restlessness, sharp, unmeaning cries, 
and a wild expression of the face, and in older ones by muttering, or 
even by attempts to leave the bed. Irregular muscular movements such 
as floccitatio and subsultus, are rarely noticed ; though at times these, 
and even spasmodic rigidity of the trunk or limbs, or convulsions, may 
be present. 

We have thus sketched the course of what is, perhaps, the most common 
form of typhoid fever in children, where the disease begins gradually, and 
either remains mild throughout, or assumes a more grave character during 
the second week. 

In a certain number of cases, however, the onset of the disease is far 
more sudden and violent, and the severity of the attack is manifested 
from its earliest period. In this form, the prodromes are brief, or almost 
entirely absent ; and there may be in older children an initial chill, or the 
only symptoms present are marked debility, languor, and drowsiness. 
During even the first two or three days, however, there is apt also to be 
frequent vomiting, severe headache, or marked hebetude, and high fever, 
which usually presents the same marked morning remissions and evening 
exacerbations as in the milder form. The sleep is restless and disturbed, 
and the child either utters sharp cries, or, if older, talks incoherently. 
The pulse and respiration are much accelerated, and the temperature of 
the surface rapidly rises, till, by the end of the first week, it may reach 
103'-" or 105°. The cerebral disturbance may mask the presence of any 
abdominal pain ; and as it is not unusual for the bowels to be quiet for 



SYMPTOMS. 831 

the first few clays, the case may closely simulate some acute cerebral dis- 
order. By the end of the first week the disease is developed in its full 
severity. The fever is more nearly continuous, the morning remissions 
being comparatively slight, and the skin remains constantly dry and hot. 
There is deep stupor, from which the child is roused only with much dif- 
ficulty, and which occasionally alternates at night with restlessness, jacti- 
tation, and noisy delirium. The pulse is very frequent and feeble, and 
the breathing accelerated, and usually accompanied with bronchial rules. 
The vomiting ceases, but the abdomen becomes tympanitic, and there is 
more or less abundant diarrho?a ; the stools are often passed quite involun- 
tarily, and the urine is either retained or dribbles away unconsciously. 
Epistaxis occurs in a large proportion of cases, and about this time the 
characteristic rose-colored eruption makes its appearance. During the 
second week, all of the symptoms become more grave, and the patient 
may succumb to the violence of the disease, or remain for a week or ten 
days plunged in profound stupor, with subsultus and marked muscular 
tremor ; with the lips and teeth coated with sordes, the tongue tremulous, 
dry, and coated with brown crusts, the abdomen tympanitic, and the stools 
frequent, thin, and passed involuntarily ; with the pulse running, feeble, 
from loO to 160 in the minute ; the respirations shallow, imperfect, and 
attended with subcrepitant rales, indicating passive congestion of the 
luDgs; with the urine retained, dark-colored, and even albuminous; and 
yet gradually emerge from this apparently hopeless condition to enter 
upon convalescence about the close of the third week. 

In favorable cases, between the fifteenth and twenty-first day, the grave 
symptoms begin to abate. The child's expression becomes more natural, 
and often the earliest sign of approaching convalescence will be the ap- 
pearance of a smile of recognition, or of pleasure at the consciousness of 
improvement. The fur upon the tongue becomes looser, moister, and be- 
gins to separate, and the appetite slowly returns ; the distension of the 
abdomen diminishes, and the stools are again passed consciously and vol- 
untarily, and gradually assume a healthy appearance. Restlessness and 
delirium disappear, and the sleep becomes quiet and refreshing ; the fever 
subsides, and the temperature falls, and again shows a marked difference 
between the morning and evening. The child thus passes into a state of 
convalescence, which, when not disturbed by complications, is quite rapid, 
though attended with marked emaciation, extreme debility, and feebleness 
of digestive power, with a tendency to intestinal disturbances. In some 
rare cases, at times without a.ssignable cause, at others from improper ex- 
posure or exertion, or indiscretions in diet, the patient suffirrs a relapse, the 
original symptoms reappear, and a second fully developed attack of typhoid 
fever, attended with marked nervous symptoms, characteristic eruption, 
and diarrhoea, may ensue. 

In ven»' severe cases, on the contrary, and especially when a fatal result 
18 to follow, the condition of the patient grows more and more grave after 
the end of the second week, unless, as at times happens, death has occurred 
sooner from the violence or malignancy of the attack. The nervous symp- 
toms become more marked, and the child sinks into a dee[>er stupor, even 



832 TYPHOID FEVER, 



1 



approaching true coma, or the stupor is interrupted by violent agitation, 
with cries or efforts to leave the bed, or by muscular twichings, picking at 
the bed-clothes, or even general convulsions. The pulse is very rapid and 
small ; the respirations hurried and noisy, and physical examination fre- 
quently reveals the existence of extensive bronchitis or hypostatic pneu- 
monia. Vomiting is rarely present, but hiccup may be frequent and dis- 
tressing ; the belly is enormously distended, the stools frequent, involuntary, 
and at times bloody. Bed-sores form on points subjected to pressure, and 
death ensues amid profound stupor and with signs of extreme pulmonary 
obstruction. 

At other times death occurs not so much from the extreme violence of 
the disease itself as from the development of some one of the complica- 
tions which will be mentioned hereafter. 

Special Symptoms. — Although, as has been seen, the general course of 
typhoid fever is much the same in children as in adults, there are a few 
symptoms which require more detailed notice, as presenting peculiarities 
which impress special features upon the disease as it occurs in childhood. 

Prodromes. — In children, as in adults, typhoid fever is nearly always 
preceded by a marked prodromic stage, and the passage from the state of 
health to the fully developed disease is usually very gradual. The dura- 
tion of these prodromes varies from three or four to ten days, being least 
in the more severe cases. 

Fever. — Condition of Skin. — We have already remarked that, in the 
early stage, there are apt to be very marked remissions in the febrile action, 
lasting even throughout a considerable part of the day ; the exacerbations 
of the fever usually occurring towards evening. West states that in some 
few instances two distinct remissions and exacerbations may be noticed in 
the course of every twenty-four hours. It is this feature which gained for 
the disease the name of infantile remittent fever, and caused it to be ranked 
formerly with the malarial diseases. Towards the middle of the second 
week, however, the remissions become much less marked ; the temperature, 
which in some cases reaches 104° or 105°, merely presenting a somevv'hat 
marked fall in the morning. In general terms it may be said that the law 
of the accession of febrile temperature in typhoid fever in children, although 
in general correspondence with that found in adults, presents occasional 
marked eruptions. Thus, in some instances, the onset is so abrupt that a 
temperature of 104.5° has been noted by Roger on the first day, while it 
w^ill be remembered as a law laid down by Wunderlich for the typhoid 
fever of adults, that the disease is never attended by a temperature of 104° 
so early as the second day. The skin is hot and dry as a general rule, but 
sweats are more apt to occur during the height of the disease than they are 
in adults ; they are not, however, of any prognostic value. 

Digestive Symptoms. — Among the earliest and most important symptoms 
are various disturbances of the digestive functions. The appetite rapidly 
fails, and is often lost before the attack fairly begins. Thirst is, however, 
marked until dulness of the mind appears, after which it also may be en- 
tirely absent, though the child will usually drink if cold water be offered 
to it. The tongue is always furred, usually being covered throughout the 



I 



SPECIAL SYMPTOMS. 833 

course of the disease by a thick yellowish-whito coat, which may reniaiii 
moist and hiose, or, in very grave cases, become dry and brownish. Sordes 
are not often observed. Vomiting, which is perhaps not more frequently 
met with iu the early stage in children than in adults, may be very frequent 
and persist until far into the second week. In the majority of cise^, diar- 
rhiva is either present or the bowels are peculiarily sensitive to the action 
of laxatives. In some cases, however, and especially those where vomiting 
is marked, constipation of a quite obstinate fqrm is present. The conjunc- 
tion of these two symptoms, iu connection with the cerebral symptoms 
present, may cause the case to strongly resemble the first stage of tuber- 
culous meningitis ; the doubt may, however, be usually resolved by careful 
examination, as will be more fully alluded to under the head of diagnosis. 

The stools, when diarrhoea exists, are ochre-colored, fluid, and, on stand- 
ing, deposit a sediment of shreds of mucous membrane, epithelium, and 
partially digested food. Mucus is rarely present ; but blood, in varying 
amount, may be mixed with the fecal matter. "When the amount is large, 
it is usually due to the ulcerative process in the intestine having opened a 
vessel of considerable size, and then constitutes a very grave complication. 

In young children it is difficult to establish the existence of abdominal 
pain, but, when they are capable of describing their sensations, colicky 
pain is frequently complained of in the early stages ; and even in the 
youngest children, pressure in the right iliac region may often be seen to 
be painful. 

Tympany is usually present at some time during the attack, especially 
when there is diarrhoea. Even when the bowels are confined, however, the 
abdomen is never retracted. Rilliet states that, in some grave cases, he 
observed such great tympany that the abdominal walls were thin enough to 
allow the outlines of the convolutions of the intestine to be clearly seen. 

Enlargement of the spleen nearly always exists, but frequently to so slight 
a degree that it cannot be readily detected either by pal})ation or percussion, 
and even when considerably enlarged, it is apt to be entirely hidden by the 
distension of the abdomen. On the other hand, we have repeatedly found 
this organ so much enlarged, as to be distinctly perceptible on careful pal- 
pation. 

The wnwe presents the ordinary febrile conditions, being scanty, high- 
colored and of high specific gravity ; the pigment is increased, and the 
chlorides much diminished. 

The stools are, as we have already said, often involuntary during the 
height of grave cases, after the beginning of the second week. Until this 
time, however, and throughout the entire course of more mild cases, the 
child is conscious of the desire, and can control the passage, or even wishes 
to be taken from the bed for the purpose. 

The urine is also, though more rarely, discharged involuntarily ; in rare 
cases, which may ultimately recover, retention of urine is present, and is 
of grave impr^rt. Rilliet never observed this symptom, but we have seen 
it more than once, and especially in a boy aged five years, who rcfpiired 
catbeterizatioD for several days successively, but who finally recovered. 

68 



834 TYPHOID FEVER. 

Respiratory and Circulatory Symptoms. — Even during the first week, there 
is usually more or less dry cough, with sonorous and sibilant rales over the 
posterior part of the lungs. Indeed, in some cases, we have known the 
cough and signs of catarrhal inflammation to be so marked in the first 
days of the disease, as to cause the attack to be regarded as one of severe 
acute bronchitis. Later in the disease, and owing merely to the passive 
hypostatic congestion of the lungs, and the accumulation of mucus in the 
bronchial tubes, the cough is apt to grow more frequent and troublesome, 
the respiration is hurried and oppressed, and auscultation reveals moist 
and dry rales throughout both lungs. When pneumonia or bronchitis su- 
pervene, these symptoms of respiratory obstruction increase to a marked 
degree. Extreme rapidity of breathing, with alterations in its character 
and rhythm, are also met with, however, in cases where the pulmonary 
obstruction seems moderate, but where the nervous system is profoundly 
disturbed. 

The pulse is accelerated from the very first, and during the height of the 
disease, rises to 120, 140, or even 180, according to the age of the child. 
In grave cases it may become extremely small, feeble, and compressible, 
but scarcely ever is intermitting or irregular. 

The eruption of typhoid fever in children presents precisely the same 
appearances as in the adult ; it usually appears first on the upper part of 
the abdomen, and often presents several successive crops. It is, however, 
more frequently absent entirely, and presents even greater irregularities, 
as to the date of its appearance, in them than in adults. The abundance 
of the eruption certainly bears no relation whatever to the severity of the 
attack; and in a varying proportion of cases (7 in 30, Hillier), the most 
careful daily examination fails to detect the characteristic spots at any 
period of the case. The eruption makes its appearance in a large majority 
of cases between the sixth and twelfth days, but the first spot has been ob- 
served so late as the twenty-fifth day (Hillier), or the twenty-ninth 
(Rilliet). 

Sudamina are frequently present in large numbers at any time after the 
ninth day. 

It is very important to be aware that in some cases, owing to the pecu- 
liar state of the cutaneous circulation, a marked reddish streak will be 
produced if the finger be somewhat firmly drawn across the skin. This 
sign, which we have described under the name of " tache meningitique," in 
our article on tubercular meningitis, does not therefore possess the high 
degree of diagnostic value accorded to it by Trousseau and others, which 
would make it of much use in doubtful cases. 

Epistaxis is very rarely abundant, but is met with in a majority of cases 
at some period after the third day. 

Nervous Symptoms. — In none of the symptoms of this disease is such va- 
riety observed as in those furnished by the nervous system. 

In mild cases, consciousness is retained throughout the attack ; the ex- 
pression of the face is stupid and heavy ; the child is dull and disposed to 
doze during the day, but becomes feverish and restless towards night, and 
sleeps uneasily and wakes frequently. 



SPECIAL SYMPTOMS. 835 

In more severe cases, the nervous symptoms soon become prominent. 
The tace assumes an almost characteristic expression ; the eyes are dull and 
vacant, or bright and excited during temporary delirium ; the cheeks pre- 
M nt a circumscribed flush; the lips are dry and parched; and the features 
remain almost motionless. 

Headache is sometimes complained of, and without doubt exists in many 
cases when the child is too young to call attention to it. It is especially 
observeil in the early part of the attack, when there may be some hebetude 
and deafness present, and, according to Dr. Jenuer, ceases upon the ap- 
pearance of delirium. 

This latter symptom rarely appears in marked degree before the second 
week, but then may become violent, the child crying out loudly, or mutter- 
ing incoherently, and struggling violently to leave its bed. The delirium 
is rarely continuous but is more marked during the night, being replaced 
during the day by more or less profound stupor, which, however, rarely 
amounts to actual coma. 

Subsultus and carphologia, as well as muscular rigidity, are compara- 
tively rarely observed in children, and only in very grave cases. Convul- 
sions, even of a general and violent character, are met with in a very small 
roportion of cases ; they may occur in the early stages of cases which sub- 
sequently recover, or as one of the final phenomena in fatal cases. They 
are, however, at whatever stage they present themselves, of very great 
import. In a case mentioned by West, the convulsions recurred on two 
successive days at the middle of the third week of the fever, and were suc- 
eeded by hemiplegia, which continued, though gradually diminishing, for 
four days. The child was unconscious even before their occurrence, and 
continued so for several days, though he eventually recovered. 

As a general rule, the course of typhoid fever is much less apt to be at- 
tended by any complication in children than in adults; there are, however, 
some which occur with considerable frequency. 

We have already stated that cough and signs of slight bronchitis are 
fretjuent in the early stage. In a considerable number of cases these symp- 
toms become aggravated as the case progresses, and there may be a devel- 
opment of general bronchitis or even pnjeumonia; more frequently, how- 
ever, the condition of the lungs is rather one of hypostatic congestion than 
of true inflammation. These complications, when present in a marked 
degree, protract the case and add greatly to it** danger. Pleurisy is com- 
paratively rare. 

Perforation of the ileum, from ulceration of Peyer's patches, is more 
rare in children than in adults; but when present gives rise to the same 
vraptoms, and leads to an equally rapidly fatal result. In some cases, its 
urence is announced by an attack of convulsions (Rilliet). We have 
.».( .i.jy alluded to the fact that we have known violent general |KTitonitis 
to be excited by extension of inflammation without the occurrence of actual 
perforation of the bowel. 

Intestinal hajraorrhage, on the other hand, is comparatively frequent ; 
thus Hillier observed it four times out of thirty in which the stools were 



836 TYPHOID FEVER. 

carefully examined. It is usually of grave significance, but is at times 
seen in mild cases, which recover readily. 

Earache is not infrequently observed after the height of the disease ; in 
some cases it is followed by abundant purulent discharge. 

Inflammation of the parotid gland is much less frequent than in adults, 
as is also phlegmasia alba dolens, of which, however, there are instances on 
record. 

There is very little tendency to the formation of bed-sores in children, 
and with care in the management of the patient, they will scarcely ever 
occur. In some epidemics, gangrene of other parts, as of the vulva or 
cheek, have been observed in a few instances. Angina, and occasionally 
pseudo-membranous laryngitis, have also been noticed. 

We have seen that the urine is at times albuminous, and in these cases 
there is undoubtedly an intense congestion of the kidneys, which in very 
rare instances eventuates in Bright's disease. QEdema is not usually pres- 
ent, even when there is albuminuria, though Rilliet records two cases where 
anasarca, accompanied by albuminous urine, appeared on the fifth day, 
and lasted about a week. When oedema appears late in the course of the 
disease, it is probably to be rather attributed to a watery state of the blood 
and the debility of the circulation. 

AVe have already seen that the febrile movement in typhoid fever, in 
children, presents such marked remissions, as to have led many observers 
to apply the name infantile remittent fever to the disease. We must bear 
in mind, however, that it is far from being rare for a true malarial element 
to be present, complicating the case, and constituting it a typho-malarial 
fever. 

During the height of the disease, it is rare for any of the other eruptive 
fevers to make their appearance ; but during convalescence, variola, rube- 
ola, and scarlatina, have all been occasionally observed to appear, and run 
through their regular course. 

Tuberculosis is by some regarded as one of the most frequent of the 
sequelse of typhoid fever in childhood ; and in some cases, indeed, it ap- 
pears as though the extreme debility of constitution induced by the disease 
favored the development of tubercle in children with hereditary predispo- 
sition. In other cases it is probable that the production of tuberculosis 
after typhoid fever depends upon the infection of the system by the prod- 
ucts of cheesy metamorphosis derived from some of the mesenteric glands, 
which, instead of returning to their normal state, have undergone this form 
of degeneration. It is probable, however, that in some cases also the early 
stage of acute tuberculosis has been mistaken for typhoid fever, with which, 
as will be more clearly pointed out, it possesses some strong features of 
resemblance. 

Various disturbances of the nervous system may occur as sequelse of 
typhoid fever in childhood. Among these may be mentioned paralysis, 
either in the forms of paraplegia, or limited to a single nerve-trunk, chorea, 
and locomotor ataxia. 

Convalescence. — The convalescence is, as in adults, tedious and un- 
certain. The child often remains for many weeks in a condition of great 



DURATION — PROGNOSIS — DIAGNOSIS. S37 

debility, and with such extreme uervoiis exhaustion, that liydrencephaloid 
symptoms may even be present. 

The digestive system also manifests this debility in a most marked de- 
gree, and it requires the greatest tact and care to encourage the child to 
eat, and at the same time, to regulate the diet, since the sliglitest imlis- 
cretiou will serve to excite serious symptoms. Not rarely death ensues 
many weeks after the termination of the disease itself, in a state of intense 
emaciation, the child being worn out by persistent diarrhiwa, which resists 
all change of diet and treatment. 

We have already alluded to the fact, that occasionally relapses have 
been observed, either without cause or following some trifling indiscretion, 
in which the symptoms of the fully developed disease have reappeared and 
gone through their regular course. 

Duration. — The duration of the fever varies according to the severity 
of the case. Even in the mildest forms it rarely begins to subside before 
the end of the second week, while much more frequently it is protracted 
until from the twentieth to the twenty-third day. In many cases, indeed, 
convalescence cannot be said to be fairly entered upon beft)re the end of 
the fourth week. 

Prognosis and Mortality. — The symptoms and conditions which in- 
dicate a favorable or unfavorable termination to the case are the same as 
]^resent themselves in the adult, and may be readily gathered froui the fore- 
going description. The mortality of typhoid fever is, however, decidedly 
less in children than in adults, partly owing to the comparative rarity of 
dangerous complications, and partly to the fact that the disease is usually 
of a less severe type. In mild cases, death scarcely ever occurs ; and even 
in the more severe forms, the mortality is only from 5 to 10 per cent., under 
favorable hygienic circumstances. 

DiAGNOfiis. — We have already stated that, partly owing to the imperfect 
recognition of typhoid fever, and partly to the various names which were 
lr^<'>ely applied to this disease as occurring in children, it was formerly 
frequently confounded with other affections. 

There are, however, several disea.se8 from which it is not always easy, 
even with our improved knowledge of its peculiar symptoms, to distin- 
guish it. 

Thus, in some cases of gastro-enteritis, such as are not rare among chil- 
dren, and especially when the disease assumes a typhoid form, the resem- 
blance to typhoid fever is so great as to have led Uilliet and Barthez to 
assert that it is impossible to make a differential diagnosis. 

It should be borne in mind, however, that typhoid fever may often be 
traced to epidemic or endemic influence, and occasionally to contagion ; 
that it is ver}' rarely possible to assign any direct exciting cause for the 
attack ; and that it especially attacks children over five years of age, com- 
paratively rarely those between two and five years, and very rarely those 
under the former age. Its onset is usually more gradual ; the vomiting 
and diarrhoea are rarely so marked; the fever is more intense, the low* of 
strength greater and more rapid; while the niarke<l dulness altornating 
with delirium during the night, the occurrence of the characteristic cnip- 



838 TYPHOID FEVER. 

tion and of epistaxis, and the more fixed duration, form a group of symp- 
toms which should serve, when present, to clearly distinguish these two 
diseases. 

In some cases, as already stated, the pulmonary complication, either in 
the form of diffuse bronchitis or of pneumonia, appears so early and causes 
such marked symptoms as tend to conceal those of the constitutional dis- 
ease, and render care necessary to avoid overlooking it entirely. 

On the other hand, it occasionally happens, and more frequently in 
children than in adults, that cases of pneumonia assume a typhoid condi- 
tion, and present very, many of the general symptoms of typhoid fever. 
It will, however, usually be sufficient in cases of this kind to pay careful 
attention to the early symptoms and mode of development of the disease, 
as well as to the existence or absence of the characteristic symptoms of 
typhoid fever, such as diarrhoea, tympany, epistaxis, rose-colored eruption, 
to avoid any error in diagnosis. 

In some cases of acute, general tuberculosis, in which the deposit aflfects 
the brain, lungs, and intestinal canal, the symptoms may closely resemble 
those of typhoid fever. This form of tubercular disease may develop itself 
in the midst of seeming good health, the child losing strength and spirits ; 
fever of a remittent type soon appearing ; with vomiting, diarrhoea, tym- 
panitic abdomen, and dry, furred tongue ; and dulness of mind during the 
day, alternating with delirium at night. At the same time there is cough 
and rapidity of respiration, though the deposit in the lungs may be too 
slight and uniformly diffused to reveal itself by any positive physical signs. 

In some such cases, indeed, it is only possible to form a probable diag- 
nosis, based upon the age and previous history of the child ; for acute gen- 
eral tuberculosis appears even at the earliest ages, and especially in chil- 
dren who have an hereditary tendency to tubercular disease, or who are 
delicate and frail, or have lately passed through an attack of some one of 
the eruptive fevers, or of hooping-cough ; and upon the absence of eruption 
and the greater duration of the case. 

Usually, however, there is a sufficient ground for diagnosis furnished by 
the special symptoms, even early in the course of the case. Thus, in 
typhoid fever the vomiting in the early stage is rarely frequent or obsti- 
nate, and only follows eating ; and, though the bowels may be constipated 
for a day or two, diarrhoea soon makes its appearance, and the abdomen 
begins early to enlarge. In acute tuberculosis, on the other hand, the 
vomiting in the early stage is usually both frequent and obstinate, and 
occurs entirely causelessly; whilst the bowels are in most cases constipated, 
and the abdomen retracted until a much later period in the case, when the 
disease of the mucous membrane excites diarrhoea. The approach of fever 
in the tubercular disease is more slow, its course less regular, and its degree 
less intense, as a general rule than in typhoid fever. 

The nervous symptoms in the early stage of the two affections may be 
almost identical, but before long, in cases of tuberculosis, some of the un- 
mistakable signs of tubercular meningitis, such as strabismus or partial 
paralysis, usually appear. Epistaxis is rare in tuberculosis, and, of course, 
the characteristic eruption of typhoid fever is absent, though it must be 



TREATMENT. 839 

borne in miml that this is not constant in the latter disease. In doubtful 
oases, ophthalmoscopic examination should never be omitted, since it will 
frequently reveal lesions of the optic nerve or retina in meniniritis which 
are al^sent in typhoid lever. And, tinally, thouixh the pulmonary disease 
may in some cases of the tubercular atlection be slight, and not reveal 
itself by positive physical signs, most important aid is often derived from 
a ttireful exploration of the chest. We have already alluded to the fact 
ihal although the production of a reddish streak by drawing the finger 
over the skin is frequently observed in tubercular meningitis, the occa- 
sional occurrence of the same sign in typhoid fever deprives it of much of 
its diagnostic value. 

Treatment. — Typhoid fever in childhood requires the same general 
plan of treatment as in adults. In mild cases little else is required than 
>trict attention to all hygienic precautions, and a supporting, but fluid and 
digestible, diet. Whatever complications ensue, should of course be treated 
appropriately. There are, however, a few indications in regard to which 
it may be well to speak more in detail. 

When the fever is high, febrifuges, such as liq. ammoniie acetatis and 
sp. anheris nitrosi should be given ; to which a little syr. ipecac, may be 
added, if the cough be troublesome. The surface of the body should be 
-ponged daily or several times a day with tepid water, to which a little 
vinegar may be added ; or the child may be carefully lifted for a few min- 
utes every day or every other day into a bath of about 65° to 75°. 

If there is much gastric irritability in the early stage, food should be 
given in very small quantities, and should be of the lightest character, as 
milk with lime-water or weak beef extract ; counter-irritation may be em- 
ployed in the form of mustard-plasters to the epigastrium ; or, if there be 
reason to think that the stomach contains undigested, irritating food, an 
emetic of ipecacuanha may be given. In cases where marked symp- 
toms of gastro-hepatic disturbance occur at the beginning of the attack, a 
few small doses of calomel with bismuth, or of blue mass, followed by a 
very gentle laxative, will be followed by relief to these symptoms. If the 
bowels are constipated, very small doses of some mild laxative, as castor 
oil or syr. rhei aromat., should be given during the first week ; but when 
spontaneous diarrhcea is present, it should, unless it becomes excessive, not 
be interfered with. When, however, the stools exceed three or finir daily, 
f balk mixture, with some vegetable astringent and opium, or small doses 
of opium and acetate of lead, or of paregoric alone, may be administered. 

In ordinary' ca.ses, the nervous symptr^ms scarcely require any especial 
attention. When, however, they become marked, it will often suffice to 
apply wet cloths to the head, and to administer warm mustard foot-baths 
to allay the agitation. In cases where delirium becomes extreme, with 
great nervous agitation, the above remedies should still 1)C used, but, in 
addition, small dfjses of chloroform with camphor-water, or even of opium, 
-h<^«uld be given, and will often prcxluce the happiest effect. Dr. West 
-j.« aks highly in such ca-ses of the combination of opium and tartar emetic, 
r.r.mmended by Graves in the treatment of the head symptoms of typhus 
lever. It will be found, also, that chloral, in doses of five grains at three 



840 TYPHOID FEVER. 

to five years, or of bromide of potassium, in doses of seven to ten grains 
at the same age, repeated according to the urgency of the symptoms and 
the effect produced, will often prove successful in affording relief. 

In regard to the occurrence of complications, we have already alluded 
to the remedies by which diarrhoea is to be checked if it becomes excessive. 
When the symptoms of pulmonary obstruction become marked, frequent 
counter-irritation by mustard or turpentine should be applied to the chest, 
and stimulating expectorants, as carbonate or muriate of ammonia, ad- 
ministered internally. 

Haemorrhage from the bowels and peritonitis from perforation or exten- 
sion of inflammation, must be treated exactly as in the adult, the one by 
astringents, either vegetable or mineral, or by ergot and moderate doses of 
opium ; the other by the free use of opium. 

Of the special remedies which are recommended in this disease, we may 
allude to the treatment by means of mineral acids, especially the muriatic 
and nitro-muriatic, which is highly praised by some authorities. 

Quinia is necessary in many cases as a tonic when adynamic symptoms 
begin to appear, and is of service in cases attended with high temperature, 
when given in full doses with a view of reducing the excessive heat of the 
body. In some cases, also, where the remittent character of the fever is 
marked, and where there is a suspicion that the case is complicated with a 
malarial element, it should be administered in full antiperiodic doses in 
the earliest stages. 

Opium is rarely necessary in the early part of the disease, unless it be 
required to check diarrhoea ; but when, in the latter part of the second or 
third week, the delirium becomes extreme, and the child sleeps but little, 
the night being spent in violent restless agitation, with loud screaming, 
opium should be fearlessly given until quiet sleep is produced. 

The oil of turpentine is to be administered under the same conditions 
which call for its use in adults. 

Stimulants are by no means absolutely necessary in all cases of typhoid 
fever in children. Excepting in the very mildest, however, it is prudent 
to administer them in small quantities after the middle of the second 
w^eek. When, however, the condition of the child calls for their more 
free use, as shown by the frequent feeble pulse, rapid labored breathing, 
dry, brownish tongue, dulness alternating with noisy delirium, and other 
marked nervous symptoms, they should be given to the extent of f^iij to 
f^vj of sherry wine, or even of brandy, to children of six years old. It 
will be found in these cases that even such large amounts of stimulants 
as the above are very well borne by children. 

The food should be given in small quantities, and frequently repeated. 
It should throughout the entire course of the disease be exclusively fluid, 
consisting of milk, chicken-water, or the various animal broths. It is 
rarely difficult to regulate the diet of children suffering with this disease, 
since their entire loss of appetite renders them indifferent to all food, and 
they will usually take whatever is offered to them. 

During convalescence, the utmost care must be exercised, both in 



TREATMENT. 841 

regard to food and exercise. Solid food should be permitted very grad- 
ually, aud with much caution: bci^inning with the liirlitcst and most di- 
gestible forms, and watching the manner in which each article is digested. 
In those cases where the child remains a long time in a condition of 
extreme debility, with impaired power of digestion, the bitter tonics and 
iron should be given, if the stomach will tolerate them. Sea, or cold 
water bathing, change of residence, and the utmost attention to all hygi- 
enic rules, are also to be recommended. When there is any reason to 
dread the development of tubercular disease, this treatment must be car- 
ried out with the greatest assiduity ; and, if the child can digest it, cod- 
liver oil may be given with advantage. 



CLASS VI. 

CACHECTIC DISEASES. 
ARTICLE I. 



SCROFULA. 



It does not seem appropriate, in a work whose chief character is de- 
signed to be practical, to enter upon a full discussion of the important 
pathological questions connected with the subject of scrofula, particularly 
in regard to its relations to simple chronic inflammation on the one hand, 
and to tuberculosis on the other. Indeed, in some respects these questions 
may be said to be still in such an unsettled state that no definite position 
in regard to them can be assumed with confidence. We propose therefore 
to confine our remarks at present chiefly to a description of the most 
marked manifestations of scrofula as generally recognized, and to a dis- 
cussion of the appropriate treatment. 

Definition ; Characters. — The term scrofula is of very long standing. 
It appears to have been originally applied to a peculiar cachectic state of 
the system in which there is a special tendency to enlargement of the 
lymphatic glands. Subsequently it has been employed in so many and 
such varied senses as to make it difiScult in many cases to decide in which 
way it is meant to be understood. We ourselves would be understood to 
employ it much in the old sense, to indicate a peculiar constitutional con- 
dition in which there is a " vubierable^' or irritable state of the lymphatics, 
which renders them liable to become enlarged from trifling causes, and at 
the same time indisposed to healthy reparative action ; and which is also 
apt to manifest itself by various obstinate chronic inflammations of the 
skin, mucous or synovial membranes, or bones. 

Scrofula is undoubtedly closely associated with tuberculosis. It very 
often happens that the children of tuberculous parents are scrofulous. 
And again we frequently observe that patients who have suffered with 
some chronic scrofulous aflfection become the subjects of tuberculosis, even 
of the most acute miliary form. So also there is a stage, that of yellow 
cheesy degeneration, in which it is not possible to distinguish between 
products of a scrofulous and of a tuberculous character. Still, however, 
we do not regard these two cachexise as identical, and enough points of 
difference can be indicated to fully support this opinion. Tuberculosis, it 
is true, often follows scrofulous affections, just as it follows any other con- 



r 



scrofula: causes — symptoms. 848 



dition attended with the formation of cheesy deposits, which may infect 
the system and give rise to acute miliary tuberculosjis. On the other liand, 
it is not common for tnbercuhnis subjects to devcK)p any manifestations of 
scrofula; and, as West points out, we frequently see whole families which 
display one or the other diathesis in its most intense form, and yet per- 
fectly uncomplicated. Scrofula, moreover, is, far more markedly than 
tubercuUisis, a disease of early life. The most common and characteristic 
of its manifestations also are very different from those of the latter dis- 
ease ; it affects the bones, the skin and adjacent mucous membranes, the 
glands, the synovial membranes in preference to the serous membranes, 
the lungs, the solid abdominal organs, and the alimentary and respiratory 
mucous membranes. These differences in the leading pathological tenden- 
cies of these two great cachexia?, as well as the many points of difference 
in the physical peculiarities of children who are liable to tuberculosis or 
scrofula, are clearly and forcibly pointed out by Jenner in a clinical lec- 
ture published in The Medical Times and Gazette, 1860, p. 259. 

Causes. — Scrofula is, we think, in many cases undoubtedly due to in- 
herited predisposition. As in the case of other cachexiie, the actual disease 
is not transmitted from parent to oflJspring, but merely so strong a tendency 
to its development that in some cases no care or favorable hygienic in- 
fluences will overcome it. Not only do we meet with scrofula in the 
children of parents who themselves have been scrofulous, but also in cases 
where a feeble and vitiated constitution has been inherited from parents 
aflTected with tuberculosis or constitutional syphilis. In other cases, it is 
doubtedly acquired after birth, appearing in children born to parents of 
sound constitution. The causes which tend to thus develop it act by im- 
pairing the nutrition, and include such influences as insuflicient, improper 
food, protracted exposure to damp, cold, and especially to vitiated atmos- 
pheres, attacks of certain diseases, which like measles, typhoid fever, and 
chronic malaria, exercise a remarkably injurious action upon nutrition. 

Symptoms. — Although by no means all scrofulous children present the 
same physical peculiarities, there are yet certain features so commonly 
met with in such subjects as to have led to their recognition as forming 
together the symptoms of a scrofulouJi diathem^. Thus, as a rule, such chil- 
dren are heavy and lethargic in mind, and of phlegmatic temperament, 
with dull expre,^«ion, and thick, opaque skin. The features are apt to be 
coarse, especially the lips and nose ; the lymphatic glands are perceptible 
to the touch ; the abdomen is apt to be full and large; and the bones arc 
large, with coarse, thick ends. 

There is nothing peculiar or pathognomonic about the special manifesta- 
tions of scrofula. Alnif^st all of them may also appear as simple idio- 
pathic affections due to some definite exciting cause, in children of entirely 
sound constitution. That which characterizes these same affections when 
they occur in what we term the scrofulous form, are the trivial causes 
which excite them, the inveterate obstinacy with which they persist, and 
their association with other analogous phenomena in the same subject. 
There is also in some cases a certain order of succession of the manifesta- 
tions of scrofula which has even led to the division of its course into 



844 SCROFULA. 

three stages, corresponding somewhat to the classic phases of constitutional 
syphilis. Thus in the earliest stage, the lymphatic glands and skin are 
chiefly affected ; subsequently affections of the mucous membranes and 
cellular tissue make their appearance ; and in the final and most aggra- 
vated form the bones and viscera suffer. We cannot affirm, however, that 
this division and order of succession of the manifestations of scrofula is 
by any means constant or even marked in many cases. 

Most of these manifestations appear as chronic inflammation of the part 
affected. At times such inflammation seems to arise spontaneously, while 
more frequently some more or less trivial exciting cause can be assigned. 
Thus the scrofulous enlargement of any group. of glands is apt to be pre- 
ceded by irritation of the area whose lymphatics pass to the affected glands, 
as, for instance, enlargement of the cervical lymphatics follows eruptions 
on the scalp or behind the ears, or attacks of sore throat. 

Among the most frequent affections which are generally classed as 
scrofulous may be mentioned, without any reference to their frequency of 
occurrence, enlargement of the superficial lymphatic glands, cutaneous 
eruptions, especially of the vesicular and pustular varieties, small sub- 
cutaneous abscesses, chronic inflammation of the mucous membranes which 
are continuous with the external skin, as of the conjunctiva, the membrane 
of the external auditory meatus, that of the nose, and of the vulva and 
vagina, chronic effusions in the synovial membranes, chronic ostitis with 
caries. 

The reader is referred for more detailed accounts of these numerous 
local scrofulous affections, to the special works which treat of the diseases 
of the skin or organs of special sense, or to general treatises upon surgery. 
Our own purpose is of necessity limited to a discussion of the general 
symptoms and treatment of the scrofulous cachexia, rather than of its 
numberless local manifestations. In the most advanced and severe forms 
of scrofula, lesions of various internal viscera may be developed. Among 
the most frequent and clearly marked in their nature, of these, are caseous 
bronchitis and pneumonia, and albuminoid degeneration of the abdominal 
viscera, the liver, spleen, and kidneys. Bronchitis and pneumonia at 
times appear in forms which entitle them to be regarded as scrofulous from 
the first. At other times, they apparently originate as acute inflammatory 
affections, but which, owing to the strong scrofulous diathesis of the patient, 
pass into a chronic form characterized by the low grade of the morbid 
products developed, by the obstinate and intractable course the affections 
run, and by the marked tendency to the occurrence of caseous degenera- 
tion and destructive changes in the diseased parts. In this condition, a 
sudden development of miliary tuberculosis not rarely occurs, either in the 
adjacent portions of the diseased organ, or throughout the other parts of 
the system. The exact nature of the primary changes in such cases is, at 
the present moment, one of the most unsettled and disputed points in 
pathology. The reader will find a tolerably full description of the lesions 
and symptoms under the head of pulmonary phthisis. 

The exact relation of albuminoid degeneration of the viscera to scrofula 
is also somewhat uncertain. Although one of the most frequent of the 



SYMPTOMS — DIAGNOSIS. 845 

unfavorable sequelte of scrofulous aflections, it cannot itself be regarded 
as scrofulous in nature, since it makes its appearance in connection with 
other cachectic states of the system. The attempt of Dickinson to asso- 
ciate it with the changes in the blood and tissues caused by prolonged sup- 
puration v^which so often occurs in scrofulous disease of the bones, joints, 
or glands ), has not been altogether successful. Ahliough it is undoubtedly 
true that in many cases where albuminoid degeneration has been devel- 
oped there has been previous prolonged suppuration, there are many ex- 
ceptions where the visceral lesions have apparently been induced directly 
in connection with the scrofulous or other cachexia. The occurrence of 
this sequel must always be anticipated with anxiety in protracted and 
severe cases of scrofula. Although usually involving, simultaneously or 
in rapid succession, the various abdominal organs, the liver, spleen, kid- 
Deys, and gastro-intestinal canal, it may present a marked localization, for 
an indefinite time, in any of these parts. 

When one of the above solid organs is affected with advanced albumi- 
noid degeneration, it is found enlarged, though still preserving its origiual 
shape ; the peritoneal capsule is unchanged ; and on section the tissue pre- 
sents a homogeneous, waxy, or lardaceous appearance, which is associated, 
when the section is examined by transmitted light, with abnormal trans- 
luceuce. The intimate nature of the change consists in an infiltration of 
the organ with a peculiar structureless albuminoid neoplasm or exudation. 
This first affects the walls of the arterioles, and later the glandular cells 
of the organ. 

When the kidneys are involved, there is usually oedema, which appears 
early and increases rapidly; the urine is abundant, clear, with but slight 
reduction in its specific gravity, contains a large amount of albumen, and 
deposits numerous hyaline tube-casts. Albuminoid disease of the liver 
and spleen usually coexists. These organs are markedly enlarged, as can 
readily be detected by palpation and percussion. There is usually ab- 
dominal dropsy, with distension of the subcutaneous veins of the abdom- 
inal walls; and frequently there is also albuminuria and diarrho'a from 
coexisting disease of the kidneys and intestine. We have much less fre- 
quently observed marked albuminoid disease of the gastro-intestinal canal 
than of the solid abdominal organs, as above described. When it occurs, 
the walls of the stomach or inie.<tine are thickened and present a peculiar 
homogeneous, glistening, and infiltrated appearance. The same microscopic 
changes are found as already described. The lesion of the mucous mem- 
brane is usually attended with chronic diarrhcea, and, if the stomach is 
also seriously involved, frequent and obstinate vomiting. Hiemorrhages 
from the bowels have been observed, but much less frequently than in the 
same condition in the adult. The general symptoms which mark the later 
stages of fatal cases of scrofula, especially when these serious visceral 
lesions have been developed, are expressive of the most profound anicmia 
and malnutrition. 

D1AGXO6I8. — The recognition of the existence of scrofula dei)end8, not 
so much upon the presence of any special symptom or local affection, as 
upon the general marks of the scrofulous diathesis, the existence of hered- 



846 SCROFULA. 

itary tendency, or of some of the well-known exciting causes ; the spon- 
taneity and order of evolution of the phenomena ; and finally their in- 
tractable resistance to the ordinary remedies, and the marked benefit 
which is often found to follow the use of special antiscrofulous treatment. 

Prognosis. — The prognosis in cases of scrofula must of course depend 
upon the intensity of the diathesis, the gravity of the local manifestations, 
and the hygienic surroundings of the child. When the general health is 
fair, and the only scrofulous affections present are superficial, although 
the case is likely to prove obstinate and tedious, complete recovery can 
often be insured. It must never be forgotten, however, that such children 
are liable to the recurrence of scrofulous disease in some other form, and 
even to the development of the grave visceral lesions we have above al- 
luded to. In the later and more advanced stages of the cachexia, when 
serious disease of the osseous and glandular tissues exists, the prognosis 
becomes in the highest degree unfavorable. 

Treatment. — A great variety of local treatment — both medicinal and 
operative — is required for the various local scrofulous affections. We shall 
not, of course, attempt even to refer to these, but shall merely allude to the 
general principles that we think of prime importance ; that, in the first 
place, all such affections should be cured as promptly as possible, and also 
that, in their treatment, the essential value of proper hygiene and consti- 
tutional remedies should never be forgotten. 

The preventive treatment is of the greatest value ; but it merely consists 
in the employment, with special and continued care, in the case of any 
child who probably possesses a scrofulous diathesis, of all those precau- 
tions as to diet, dress, exercise, and residence, which sound hygiene would 
dictate. In children born of scrofulous or tuberculous parents, a wet- 
nurse should be secured even if the mother is able to suckle them ; and 
under no circumstances should the attempt be made to rear them on arti- 
ficial food. Later, when the child has been weaned, the diet should be of 
the most nutritious and digestible character, especially containing a large 
proportion of well-selected animal food. The utmost care should also be 
exerted as to the dress, in order that it may be adapted to the season and 
sufficiently warm to prevent the child from contracting any of the catar- 
rhal attacks, to which there is so great a liability in the scrofulous dia- 
thesis. Outdoor exercise in fair weather and gymnastic exercises indoors 
when it is unfit for the child to be exposed to the weather, must be en- 
joined. As a general rule, it may be said that the child should be en- 
couraged to spend as much time out of doors as possible, when the weather 
is fine, dry, and sunny. If the circumstances of the parents admit of it 
the residence of the child should be chosen in an elevated, dry, and com- 
paratively open part of the city, and for several months in each year it 
should be taken to the sea-shore, or to some elevated inland locality. 
While at the sea-shore, sea-bathing should be regularly followed, and 
throughout the rest of the year brine-baths, made with either bay-salt, or 
rock-salt, may be used daily. All forms of catarrhal inflammation, as 
angina, conjunctivitis, enteritis, and the like, should receive prompt and 
careful attention and be cured as soon as possible, since there is danger, if 



TREATMENT. 847 

they are allowed to continue, not only of their becoming chronic and ex- 
tremely obstinate, but also of troublesome glandular enlargements being 
induced by the protracted irritation. At\er any of the local manifestii- 
tions of scrofula which we have above enumerated have made their ap- 
pearance, the above hygienic management must be sedulously persisted in. 
There are also various medical substances which exercise a benelicial eficct 
by their alterative and tonic action upon the general nutrition. Among 
the:se the best are cod-liver oil, various preparations of iodine and of iron. 
Coil-liver oil may be used alone, or combined with the compound syrup of 
the phosphates of the alkalies and iron. 

The preparations of iodine most frequently used, and wiiich we have 
been led to prefer, are the compound tincture or solution of iodine, in the 
dose of from two to four drops three times a day, and the iodide of potas- 
sium, either alone, given in solution, as follows : 

H. — Potassii lodidi, gr. xxiv. 

Dococt. Sarsaparillae Comp., ^5^^'- 

Ft. sol. Dose, a dessertspoonful to a tablespoonful thrice daily, at three to five 
years of age. 

Or in combination with the iodide of iron, as follows : 

R. — Potassii lodidi, gr. xlviij. 

Syr. Ferri lodidi, . . . . f^ij. 

Syr. Zingiberis, f,:;x. 

Aquae, ......... f^iss. 

Ft. sol. Dose, a teaspoonful thrice daily in water, at five yonrs of age. 

It is probable that the above is the best mode in which iron can be 
administered, though it is often desirable to give it in association with 
quinia or some other vegetable bitter, in order to stimulate the appetite 
and digestion. 

Mercury, despite its powerful absorbent action, is not to be recommended 
for the treatment of scrofulous enlargement of the gland."*, in any form in 
which it is likely to prrxluce its characteristic effect upon the blood. We 
are satisfied, however, that in some very obstinate ca.ses which re.«<i8t all 
other modes of treatment, minute doses of the bichloride or biniodide 
may be employcnj without risk, and with much advantage. 

Arsenic deservedly (x-cupies a high place among the internal reme<lie8 
Id scrofula. It may be given in combination with iron or quinia ; or in 
some cases will be found of service in the form of small doses of Donovan's 
solution, the liquor hydrargyri et arsenici iodidi of our I'harmacopaMa. 

When circumstances permit, the use of certain mineral wat<r.'<, particu- 
larly if the child can have the advantage of a temporary change of resi- 
dence to the locality of the spring, is often attended with marked benefit. 
The waters which prove most useful are the sulphurated and iodo-bromatcd. 



848 TUBERCULOSIS. 



ARTICLE II. 

TUBERCULOSIS. 

This subject has received from many uathors upon diseases of children, 
far less attention than it merits, under the idea that it is merely a repeti- 
tion, upon a small scale, of the same disease in the. adult, and not possessed 
of any individual characteristics. In fact, however, tuberculosis in child- 
hood is an affection possessing characters and presenting symptoms entirely 
special, and differing from its manifestation in adult life both in causes, 
locality, and clinical history. 

Causes. — The causes which exert most manifest influence in its produc- 
tion are hereditary tendency, and all those debilitating agencies which act 
directly or indirectly upon nutrition. Of these latter causes, early wean- 
ing is the most prominent. Thus, we have met with a case where a healthy 
woman, the mother of several vigorous children, all of whom she had 
nursed, gave birth to one which she was unable to suckle, and this child, 
after pining for some months, died of an attack of tubercular meningitis. 
A bad quality of the nurse's milk, or improper artificial food after wean- 
ing, also exert a powerful influence in the production of tuberculosis ; and 
not unfrequently its development has been traced to repeated attacks of 
indigestion or diarrhoea. 

It has also a tendency to develop itself after certain acute affections, 
especially in children predisposed by hereditary influence. Of these dis- 
eases, rubeola, pertussis, typhoid fever, and, according to Greenhow, variola, 
are most frequently followed by tuberculosis. 

There is still some difference of opinion in regard to the role which 
pneumonia plays in the development of tuberculosis. When the two 
coexist, the inflammation is by some regarded as a secondary affection, 
induced by the deposit of tubercle in the lung ; while by others it is held 
that, amongst predisposed children, it is the pneumonia which causes the 
development of tuberculosis of the lung. We believe that pneumonia 
occupies each of these relations in a certain number of cases ; but reliable 
statistics upon this point are still too scanty to determine the exact pro- 
portion. 

Of recent years the influence exerted by foci of cheesy degeneration in 
the production of general tuberculosis has been established by careful 
clinical and experimental observation. In childhood the most frequent seat 
of such foci is in connection with the lymphatic glands, though they may 
also occur in connection with disease of the bones or with chronic ulcers. 

Anatomical Appearances. — The most frequent seats of tubercular 
deposit in the child are the brain, constituting tubercular meningitis, 
which has already been treated of at length ; the bronchial glands, the 
lungs, and the mesenteric glands and peritoneum. It is, however, one of 
the distinguishing features of tuberculosis in the young subject, that it is 



ANATOMICAL APPEARANCES. 849 

apt to involve several viscera simultaneously, while not unfrequently the 
lungs remain free. Thus, iu 312 children in whom Rilliet and Barthez 
found a deposit of tubercle in one or more of the viscera, the luntrs were 
healthy in 47 ; while in 123 similar instances in the adult, Louis only found 
one such exception. 

Locality. — In bronchial phthisis^ which generally accompanies pulmonary 
phthisis, but also exists as a separate affection (though according to Bou- 
chut, this is a rare occurrence), the glands are much enlarged and inclose 
tubercular matter, frequently in large proportion. This is especially 
marked iu those glands which lie along the trachea and around its bifur- 
cation, and, when many of them are involved and adherent to each other, 
they form masses varying in size from a hen's Qg<^ to a large apple. The 
deposit, which iu by far the majority of cases exists as infiltrated tubercle, 
does Dot usually soften, though cases are recorded where such softening 
has occurred, and the fluid has been discharged through an opening into 
a bronchus. Obsolescence and calcification, however, are quite common 
terminations of bronchial tubercles ; and wheu the lungs do not become 
involved in the morbid process, a cure may be effected by these transfor- 
mations. Calcified tubercle may be eliminated through a communica- 
tion between the gland and one of the air-passages ; and a few cases are 
also reported where the a^sophagus, trachea, and even the pulmonary ar- 
tery have been perforated in this manner. Most of these tuberculous 
glands are inclosed in a distinct and dense capsule, which may attain the 
thickness of one or two lines, and is usually quite vascular. This fibrous 
capsule is due to the hypertrophy of the originally delicate cellular in- 
vestment of the gland. 

Pulmonary Phthisi.i. — The anatomical characters of tuberculosis of the 
lungs in children present several peculiarities, as distinguished from the 
game disease in adults. Thus gray granulations and crude miliary tuber- 
cles frequently exist in the lungs, independently of each other and of any 
other form of tubercular deposit. In the adult, Louis discovered miliary 
tubercles unas.sociated with gray granulations only in 2 out of 123 cases, 
or in 1.6 per cent.; and gray granulations alone in but 5 more, or 4 per 
cent.; while in the child, Rilliet and Barthez found miliary tubercles with- 
out gray granulations in 107 out of 265 cases, or in 40.4 per cent.; and 
gray granulations alone in 36 instances, or in 13 per cent.; and the ob- 
servations of West, "which are based on 102 caH?s, yield 20 instances of 
the presence of miliary tubercles alone, and 1 7 of the presence of gray 
granulations alone in the tissue of the lungs." 

The great frequency with which the so-called yellow infiltrated tubercle 
is observed in early life constitutes another anatomical peculiarity, Killiet 
and Barthez, and West, having found it in from 23 to 33 per cent, of 
their cases. This condition rarely ex'inUi as an isolated state, but is found 
in conjunction with gray granulation?* and crude yellow tulwrclcH, and 
not unfrequently also with advanced tul)erculiziition of the bronchial 
glands. 

The rare occurrence of cavities in the lung?^ is a most striking p<'ruli- 
arity of phthisis in children. It is probably no exaggeration to say that, 

54 



850 TUBERCULOSIS. 

in adults, cavities are found in the lungs in 90 out of every 100 cases of 
tuberculosis ; whilst out of 265 cases of tuberculosis of the lungs in chil- 
dren that came under the notice of Rilliet and Barthez, only 77, or 29 
per cent., presented cavities ; they existed in only 23.5 per cent, of West's 
cases, and Bouchut found them in but three out of 36 cases. 

Occasionally the cavities resemble the vomicae found in the lungs of 
adults, and this occurs with more frequency as we advance beyond the age 
of six years. In other cases, the excavation is produced by the softening 
of very small tuberculous deposits, distinct, though in close proximity, 
which form small vacuoles, communicating with each other and with the 
neighboring bronchial tubes. All three of M. Bouchut's cases appear to 
have been of this form. 

In addition to these two varieties of tuberculous cavities, there is still a 
third, produced by the simultaneous softening of considerable portions of 
a lung affected with yellow infiltration. This action, which is most com- 
monly met with in very early life, and in cases which progress with great 
rapidity, pervades the whole of the tissue affected, instead of producing a 
central cavity. Cavities of this kind sometimes form very quickly, and 
involve large portions of lung, the whole of one lobe even being converted 
into a mere sac, with thin walls. 

There is another form of excavation occasionally noticed, which is not a 
true pulmonary vomica, but the result of the softening and evacuation of a 
tuberculous pulmonary gland. The diagnosis, however, may be rendered 
easy by reflecting that a pulmonary cavity of such small dimensions is 
hardly ever solitary, unless it proceeds from the softening of tubercular 
infiltration, whilst the deposit of tubercle which takes place in the neigh- 
borhood of a diseased pulmonary gland is always in the form of distinct 
deposits, not of tubercular infiltration (West). 

The last anatomical peculiarity, already alluded to, of pulmonary 
phthisis in children, is its frequent complication with tubercular deposit 
in the bronchial glands. 

Peritoneum. — Tubercular deposit on the peritoneum rarely or never oc- 
curs without the presence of a similar disease in some other parts of the 
economy. It may be either general or partial in its disposition, though it 
is far more frequently the latter. The deposit varies also in its character, 
appearing generally in the form of yellow granulations or of miliary tu- 
bercles, either isolated or united into small masses. Gray granulations, 
however, are also of quite frequent occurrence. 

The relation which the tubercles bear to the peritoneum is not uniform, 
though they are more frequently found deposited on its surface than be- 
neath it. In 86 cases examined by Rilliet and Barthez, the seat was as 
follows : intra-peritoneal in 40 ; extra -peritoneal in 22 ; both intra- and 
extra-peritoneal in 14 ; in the other 10 cases the exact seat was doubtful. 

When the deposit involves the entire extent of the serous membrane, we 
find the anterior parietes of the abdomen adherent to the subjacent struc- • 
tures, and the viscera so matted together and adherent, as to form an 
almost inseparable mass. More frequently, however, the tuberculization 
is partial, and even limited to the vicinity of a single organ. The perito- 



ANATOMICAL APPEARANCES. 851 

neura investing the diaphragm, especially that portion which is in contact 
with the liver or spleen, or the adjacent parietal ix^ritoneiim, is very often 
affected; and as tubercles rarely fail to be deposited in the peritoneum cov- 
ering these viscera, we find them firmly adhering to the diaphragm or ab- 
dominal wall. 

In some cases the omentum is the chief seat of the disease, and may either 
present numerous gray granulations scattered through its folds, or may be 
thickened or matted together from a kind of grayish tubercular infiltration, 
due to the coalescence of innumerable minute gray granulations. It is 
more n\re to find the tuberculization limited to the intestines, merely caus- 
ing adhesion of the adjoining coils. 

In examining the adhesions which are almost universally found to exist 
between the various organs and portions of peritoneum affected, we find 
them to present two elements. In the first place, the tubercular deposits 
n the adjoining surfaces gradually coalesce as they increase in size, and 
rinally unite the surfaces by more or less extensive patches of tubercular 
matter. And again, at the same time, tlie subacute inflammation cau^;cd 
by their presence leads to the formation of cellular and fibrous adhesions 
as in cases of simple peritonitis. This is well seen in cases where some 
coils of the intestine present tubercular adhesions to each other, forming 
masses which can only be separated by rupturing the walls of the bowel, 
while between other coils the adhesions merely consist of delicate and 
asily lacerated cellular bands. 

It is a well-established fact that the tubercular granulations on the sur- 
face of the peritoneum have no tendency to perforate this membrane ; but 
that the perforations which are occasionally found, especially in the walls 
"f the intestines, are due to the develo})raent and softening of the subp3ri- 
•neal tubercles, which always tend to penetrate into its cavity. This same 
law holds elsewhere, and it is on this account that the adhesions which so 
constantly form between tuberculous membranes are of such great value in 
: reventing the escape of foreign matters into the serous cavities. In the 
mtestines this action can be traced even further, and when tubercles exist 
under both layers of the peritoneum at a point of adhesion between two 
folds of inte:?tine, as softening advances, the layers of peritoneum are de- 
stroyed, and the little collection of tuberculous pus remains confined only 
by the inner coats of the two layers of bowel. Sooner or later these also 
break down, the softened tuberrle is discharged into the bowel, and a direct 
communication established between distant parts of the intestinal canal, 
as between a fold of the ileum and the a-conding or desrending rolon. 
This perforation, then, is not caused by tuberculous ulceration of the 
mucous membrane; nor does this latter affection bear any fixed relation 
to the degree of tuberculization of the pciritoneum. 

There is generally some deposit of tul)ercle in the mesenteric glands in 
the«e cases ; and when the splenic portion of the peritoneum is involved, we 
frfquf-ntly find an abundant deposit in thi» organ. 

Tub. r' ulization of the me^enterir glnndM, or tabes mesenterica, offers few 
anatomical features in addition to those present in bronchial phthir-is. It 
i-S moreover, far from being a fre^nfT.f f-.m! of the disease, for although, 



852 TUBERCULOSIS. 

according to Rilliet and Barthez, some tubercle is found in these glands 
in one-half of all tuberculous subjects, it exists in considerable quantity 
only in one out of every sixteen of the whole number. The deposit gener- 
ally appears as infiltrated tubercle, though not unfrequently miliary tuber- 
cles are present. The glands attain a size varying from that of an almond 
to a pigeon's egg, and occasionally, from the aggregation of several enlarged 
glands, a mass is formed double the size of the child's fist. 

The capsule which surrounds them is usually more delicate and less vas- 
cular than the same structure in tuberculous bronchial glands. The tuber- 
cular deposit here, as elsewhere, is liable to undergo calcification or soften- 
ing, the latter process being more frequently met with. 

Owing both to the yielding nature of the abdominal walls, which do not 
resist the forward growth of the mesenteric glands, and to the mobility of 
the adjacent viscera, we never see the same degree of compression exerted 
on surrounding structures,, as is noticed in tuberculization of the bronchial 
glands. 

Occasionally, however, adhesions may form between a tuberculoul mes- 
enteric gland and a fold of the intestine, and ultimately result in perfora- 
tion of the bowel. 

In thus describing these various lesions as being all tuberculous in their 
essential nature, we have purposely employed this term in the somewhat 
inaccurate and vague sense which was assigned to it until within the past 
few years. 

Recognizing, as we distinctly do, but one elementary form of tubercu- 
lous deposit, the gray granulation or miliary tubercle, which may, it is 
true, undergo cheesy degeneration, it is evident that many of the cases in 
which extensive and uniform cheesy deposits are found, rather depend 
upon scrofulous inflammation of the part than upon true tuberculous for- 
mation. It is comparatively rare to meet with such cheesy deposits in the 
lungs in children, while, as already described, they occur very frequently 
both in the bronchial and mesenteric glands. And, therefore, we are dis- 
posed to believe that in many cases of so-called bronchial or mesenteric 
phthisis, the enlargement and degeneration of the glands are really due to 
an inflammatory process of a low and unhealthy type, excited by the pre- 
vious occurrence of attacks of bronchitis or enteritis, and leading to the 
formation of a cacoplastic lymph, which soon undergoes cheesy degenera- 
tion. 

It is in this way, doubtless, that the comparatively numerous cases are 
to be explained in which such deposits soften and are evacuated, or undergo 
partial absorption and calcification, and where ultimately the child's health 
is restored. We have preferred, however, in the present edition, for prac- 
tical purposes, to group the descriptions of these various conditions under 
one common head, being unwilling to separate them until more extended 
study shall have more clearly demonstrated the degree of resemblance 
which exists between true tuberculous matter and such cacoplastic in- 
flammatory formations. 

Symptoms. — The symptoms of tuberculosis in children may be studied 



!| 



SYMPTOMS. 853 

under the form? of bronchial phthisis ; acute and chronic pulmonary 
phthisis ; and tuberculization of the peritoneum and mesenteric jrlands. 

Bronchial Phthisic. — In addition to the general symptoms of tuberculosis, 
which will be fully given under the head of pulmonary phthisis, the most 
marked symptoms of bronchial phthisis are those due to the mechanical 
effect of the enlarged and hardened jxlands upon the surrounding tissues. 
(^ur knowledge of the functions of the lymphatic glands is as yet so inac- 
curate that we are entirely unable to appreciate the symptoms of disordered 
action which are probably present in cases of extensive disease of these 
organs. 

Bronchial phthisis occurs in its best-marked form between the ages of 
two and six years ; and in many cases appears to be developed after some 
-evere attack of bronchitis, either accompanying measles or arising with- 
•ut apparent cause. 

The cough which, in the early stage, is hacking and not very trouble- 
some, soon acquires severity and becomes intermittent, recurring in par- 
oxysms like those of pertussis. 

The respiration becomes habitually labored and oppressed, with a pro- 
longed wheezing sound, as in asthmatic cases. 

The veins of the neck are often greatly distended, the distension becoming 
extreme during the violent paroxysms of coughing ; the face becomes puffy 
and o^dematous, a condition occasionally extending to the upper extrem- 
ities ; and, as West points out, the superficial vessels of the thorax become 
enlarged, just as those of the abdomen do in cases of cirrhosis of the liver. 
The obstruction to the return of blood from the superior vena cava is fur- 
ther shown by the occurrence of epistaxis, or even of hjemorrhage into the 
arachnoid ; and the compression of the pulmonary tissue occasionally pro- 
luces haemoptysis and oedema of the lungs. Dr. Jenner has seen hydro- 
thorax produced from compression of the vena azygos. 

The (esophagus does not always escape the encroachment of the glands, 
but may be so compressed as to produce dysphagia. 

It is hardly necessary to say that so long as the tubercular deposit re- 
mains small, it may 'exist without causing any symptoms, and it is only 
when several glands become infiltrated with tubercle, enlarged and firm, 
that they give rise either to the symptoms already cnuinerated, or to the 
physical signs below alluded to. 

Phiji^ical Sigiu. — In estimating thf value of these, it is nocessjiry to con- 
stantly bear in mind the fact that the enlarged and tuberculous bronchial 
glands, while they still surround the trachea and bronchi, also come into 
contact with the spinal column, or, in a few cases, with the sternuu). From 
their solidity, and the consequent readiness with which they are thrown 
into vibration, they transmit directly to the e^ir and seem to exaggerate 
many respiratory sounds, which are in reality produce<l at a distance from 
the thoracic walls, and which are either entirely normal or dependent upon 
a small amount of disease. 

It is also due to these relations, that the signs, both of auscultation and 
percussion, of bronchial phthisis are best detected at the summit of the 



854 TUBERCULOSIS. 

lungs posteriorly, or at the level of the vertebrae with which the enlarged 
glands come in contact. 

Our knowledge of these important considerations is chiefly due to the 
investigations of Rilliet and Barthez! 

Percussion. — In the young child in health, there is a diminution in reso- 
nance over the manubrium of the sternum, owing to the remains of the 
thymus glands; but, in some cases of marked bronchial phthisis, this dul- 
ness extends both downwards and laterally to a varying but perceptible 
degree, owing to the projection of the enlarged glands into the anterior 
mediastinum. 

More generally, however, as we have said, the tuberculous glands are in 
contact with the spinal column, so that we find dulness on percussion in 
the interscapular space as a pretty constant and characteristic symptom. 

According to Dr. Jenner, it is common to have a cracked-pot sound on 
percussing the cartilages of the upper three ribs on one or both sides. This 
is due to the fact that the enlarged glands accompanying the bronchial 
tubes frequently extend under the anterior margin of the lungs, so that, 
in percussing, the air-containing lung is compressed between the solid mass 
of glands behind and the in-driven parietes in front, and the air is forced 
out suddenly from the healthy layer of lung, producing the chinking sound. 

AusciUtation often reveals true tubular breathing over the upper part of 
the sternum, extending almost to the base of the heart. In those cases 
where a large bronchial tube is compressed or occluded, we, of course, find 
an enfeebled or extinct respiratory murmur over the corresponding lung 
segment. 

Occasionally the enlarged glands compress the superior vena cava, and 
give rise to a permanent venous hum ; or a systolic murmur, having its 
seat of greatest intensity at the second left interspace, may be produced 
by similar compression of the pulmonary artery. 

There is one characteristic, however, of this form of phthisis, which is 
especially dwelt upon by Dr. West, and which it is well to bear in mind, 
to avoid being misled. This is the frequent occurrence of great fluctua- 
tions in the condition of the patient ; so that, even when the rapid breath- 
ing, frequent cough, emaciation and loss of strength would betoken a 
speedily fatal issue, a pause will occur in the progress of the disease, dur- 
ing which the diminution of any bronchitic complication, with partial dis- 
appearance of the dyspnoea and cough, and the return of flesh and strength 
to the little patient, all tend to awaken delusive hopes. In the great ma- 
jority of cases, this respite is but brief, and the disease again resumes its 
onward course ; but there are well-authenticated cases on record in which 
the gravest symptoms have gradually disappeared, and the child has ulti- 
mately regained fair health. In these cases, the tuberculous deposit may 
either have undergone cretaceous degeneration, or, having softened and 
formed an opening into a bronchus, have been expectorated. 

The characteristics of bronchial phthisis, which we have been considering, 
are thus summed up by West : 

" 1. The frequent development of its symptoms out of one or more attacks 
of bronchitis. 



SYMPTOMS. 855 

" 2. The peculiar paroxysmal cough which attends it, resembling that 
of incipient pertusc*is. 

" 3. The groat and frequent fluctuations in the patient's condition, and 
the occasional and apparently causeless aggravation both of the cough and 
dyspnoea," 

Sifinptoms of Pulmonanj Phthi^h, — Valuable as are the general symptoms 
of tul>ereulosis in the adult, it is in tlie young chiUi peculiarily tiiat they 
reach their highest importance, owing either to the absence or the dilfieulty 
of appreciation of many symptoms which aid greatly iu the diagnosis of 
phthisis in adult life. 

It is necessary, therefore, to examine with the greatest care the child's 
hereditary tendencies, its past history, and its appearance and })hysical 
development. Thus it is iu cases 5f inherited tuberculosis that we see its 
characteristic features most strongly marked, in the tall, slim frame; the 
firm bones, with small and yielding cartilages; the delicate diaphanous 
complexion ; the fine, silky hair; the active, often precocious intelligence ; 
the ease with which the general health is affected by slight causes, and the 
peculiar proneness to catch cold on the least exposure. By careful atten- 
tion to these and other similar points, as much, or often more valuable 
information can be obtained in the phthisis of children, than from the most 
careful investigation of the physical signs. 

In enumerating the symptoms, it is unnecessary to detail those which 
exist iu common with pulmonary phthisis in the adult, save to point out 
any particular in which they may diifer as seen in the young subject. 

The cough varies much, in accordance with the varying amount of bron- 
chial irritation, being at one time scarcely troublesome, or so aggravated 
and accompanied with such violent dyspnrea, from some intercurrent attack 
of bronchitis, as to threaten immediate death. 

It not unfrequently has a somewhat paroxysmal character from the 
accompanying tuberculization of the bronchial glands. One of the most 
marked peculiarities of the cough in the j)hthisis of children is the entire 
absence of expectoration, since the secretions are either retaineil in the 
bronchial tubes, or, if raised into the pharynx, are swallowed without any 
effort at expulsion. 

Ihrmoptijiis very rarely occurs in the early stage or during tlie progress 
of the di.sea.se; and when it occurs as the cause of sudden death, is due to 
the complication with bronchial phthisis, rather than to the rupture of a 
bloodvessel in a pulmonary vomica. 

The temperature of the lK)dy is, as a rule, higher than normal, although 
it pre,«ents fluctuations on different days, and even at different hours of the 
«ame day; at times being normal, and again rising as high as 102°, or 
more. The greatest elevation of the temperature is generally noticed at 
night, and is usually accompanied by flushing of one or both checks; but 
it is rare to find the colliquative night-sweats which prove so exhausting 
to adults. 

The puUe is always accelerated, and becomes very frequent as the tem- 
perature rises. 

The fippetite is capricious, the tongue furred, and the digestion imper- 



856 



TUBERCULOSIS. 



feet ; the bowels alternate from a state of constipation to diarrhoea, and 
the stools are unhealthy in appearance, being generally putty-like or clay- 
colored. Naturally, with this disturbed state of the primse vise, nutrition 
is seriously impaired, and the child steadily loses flesh and strength. In- 
deed, in very many cases, the little patient presents merely the symptoms 
of impaired nutrition, becomes languid and drooping, and loses appetite, 
strength, and flesh, for many weeks before the development of cough reveals 
the lungs as the seat of the disease. 

Physical Signs. — We have already remarked the fact that in the investi- 
gation of phthisis, the physical signs are of much less value in the case of 
children than in adults. This arises not only from peculiarities of the 
physical and moral organization in childhood, but also from .the mode in 
which the tuberculous deposit takes place. Thus, as a rule, the deposit of 
tubercle in the lungs of children is more generally diffused and uniform ; 
so that we lose to a great degree the advantages derived in adults from a 
comparison of the results of auscultation and percussion in one part, with 
those obtained in another. For the same reason, we are also deprived of 
those signs which, in the adult, are developed in a single point : as, for in- 
stance, the coarse breathing, which is of so much diagnostic importance as 
one of the earliest signs of the deposit of tubercle at the apex of the lungs. 

Another source of difl^culty and error lies in the fact already alluded 
to, that the bronchial glands, when enlarged by the deposit of tubercle, 
as so constantly happens in conjunction with the pulmonary phthisis of 
children, are brought into contact with the thoracic walls, and transmit 
many sounds with intensified force. It is thus that prolongation of the 
expiratory sound beneath the clavicle, and jerking respiration, lose much 
of the importance they have as signs of the early stage of phthisis in 
adults. For although, when heard in children, they should always be re- 
garded as probable evidence of phthisis, they have frequently been noticed 
in cases whose progress shows the tubercular deposit to have been, at the 
most, trifling. In the same way, caution must be used not to mistake the 
blowing sound, mixed with moist rales, which is thus transmitted from a 
compressed bronchial tube containing mucus, for a large tubercular vomica. 
The only way in which this mistake, and the consequent too unfavorable 
prognosis, can be avoided, is by comparing daily the results of auscultation 
and percussion, and noticing whether they remain exactly the same, or 
whether, while the dulness on percussion over the enlarged glands persists, 
the results of auscultation vaiy from day to day with the varying amount 
of compression of the bronchus and the nature of its contents. 

A still further source of difficulty results from the loss of all the infor- 
mation which is derived, in older persons, from the vocal resonance and 
its alterations ; although it is occasionally possible to draw reliable conclu- 
sions from the resonance and fremitus of the cry or cough. And again, 
owing to the' excitability of children, patient and prolonged observation is 
required, both as to the situation, degree, extent, and duration of any ine- 
quality of breathing, before any conclusion can be drawn from it. 

Finally, the extreme, resonance of the thorax in early life tends to viti- 



SYMPTOMS OF TUBERCULOUS PERITONITIS. 857 

ate the results of percussion by preventing tlic rocoirnition of fine varia- 
tions of sonority, such as are readily (iotooted in more advanrod life. 

AVe have thus far been considering the symptoms of pulmonary phtliisis 
in its usual moderately acute form, but it is necessary to be aware that in 
some eases it deviates from this course, being at one time extn-mely rapid, 
and at another very chronic in its progress. 

In the acute cases, we often find that there has been a previous deposit 
of tubercle or of cnseous inflammatory exudation in difll^rent jxirts of the 
economy, though to so small an extent as scarcely to have interfered with 
nutrition or the performance of the functions, or to have attracted the least 
attention. 

In such a state of system, death may be produced in a few days or weeks 
by an acute development of tubercle. When this occurs in the lungs, it 
is not unfrequently attended by inflammation of the pulmonary parenchyma, 
constituting tuberculous pneumonia ; and, whatever may be the view enter- 
tained as to the relation between the inflammation and the tubercular de- 
posit, the recognition of this. latter element is of the greatest importance, 
from its bearing on the treatment to be adopted. 

In tuberculous pneumonia, in addition to the hereditary tendency and 
past history of the child, we rarely find the same heat of skin or vascular 
excitement as in pure pneumonia. The degree of oppression of the chest 
is also, from the beginning, out of proportion to the catarrhal or bronchial 
symptoms with which the case sets in. And auscultation reveals both that 
the amount of inflamed lung-tissue is not sufficient to account for the dysp- 
Dcea, and that the rales developed are of the subcrepitant and mucous 
varieties, rather than the true fine crepitant nlle of uncomplicated pneu- 
monia. 

In the chronic form of phthisis alluded to, the symptoms may be pro- 
longed during several years. They consist of progressive emaciation, 
chronic cough, with or without expectoration according to the age of the 
patient, and the physical signs of more or less advanced tubercular deposit. 
In favorable cases, it is not unusual for some degree of teniporary imj)rove- 
ment to occur in the general symptoms, and in some rare cases the child 
slowly regains good health, and the physical signs gradually diminish, 
leaving merely some dulness and feeble respiration at jH)ints where positive 
signs of advanced pulmonary disease previously existed. It is nee<lless to 
add that in such cases the nature of the morbid condition present has 
probablv been of a chronic inflammatory rather than of a truly tubercu- 
lo" tpr. 

of Tuberculous PerHonHin. — The peritoneum may either become 
implicated late in the course of general tulKTculosis, or it may be the first 
structure involved. Apart, however, frora the general symptoms of the 
tuberculous cachexia which in some cases prece<le its appearance, there are 
few svmptoms of muoh diagnrntic value during its early stag«*. Thus the 
child retains its appetite and spirit.** ; does not lose flesh rapidly ; and only 
complains of occasional and apparently causeless abdominal pain. This 
condition does not, however, last long; th'e nutrition soon fails, the appe- 
tite becomes capricious, the bowels irregular, the colicky pains more fre- 



858 TUBERCULOSIS. 

quent and severe, and the abdomen acquires an abnormal size and appear- 
ance. These symptoms, however, merit a more detailed allusion. The 
tongue rarely indicates, either by dryness or furring, any serious disturb- 
ance of the digestive functions. The bowels are almost invariably loose, 
or alternations of constipation and diarrhoea present themselves, the stools 
usually being unhealthy in appearance. This condition frequently appears 
to depend upon inflammation or tuberculous ulceration of the intestines. 
Vomiting is not usually present; it is rarely spontaneous, and merely con- 
sists in the occasional rejection of alimentary matters. 

Pain in the abdomen has been mentioned as one of the earliest symp- 
toms. It is rarely constant or confined to the seat of the lesion, but is 
rather shifting, intermittent, and colicky in its nature, recurring with 
greater or less frequency. There is also tenderness on pressure over the 
abdomen, which becomes especially marked during the later stages of the 
disease, though in some cases the abdomen remains indolent throughout. 
At a variable period after the appearance of the preceding symptoms, and 
sometimes simultaneously with the occurrence of colicky pains, the abdo- 
men undergoes a marked modification in its size and shape. It becomes 
tense and large, and assumes an oval or globular form, the depressions 
and fossse being all effaced. It generally retains its tympanitic note upon 
percussion ; and in proportion as the distension increases, the sound be- 
comes more and more tympanitic. The tension often varies without any 
apparent cause ; and when it is much diminished, an imperfect sense of 
fluctuation may be obtained by filliping the sides of the abdomen. This 
sign is rarely due to any ascites being present, but is beyond doubt rightly 
explained by Rilliet and Barthez as due to the transmission of the impulse 
of the hand by the agglutinated intestinal mass. 

It is only in very exceptional cases that even the most careful percussion 
or palpation will detect any inequalities in the abdominal walls, due to the 
presence of large tuberculous patches. In every case in which the last- 
named observers detected any abdominal tumor, the omentum was found 
to be the chief seat of the tuberculous deposit. 

After this condition of the abdomen has persisted some time, the dis- 
tended skin desquamates, and assumes a rough and dirty appearance. 
At about the same period, usually, the cutaneous veins of the abdomen 
become prominent and dilated, owing to the obstruction to the abdominal 
circulation. 

As the case progresses, and the general symptoms assume more gravity, 
these local symptoms become more pronounced. Like all forms of tuber- 
culosis in children, however, the advance of this disease is rarely uniform, 
and intermissions and fluctuations in the symptoms are often noticed. To- 
ward the close of life, all the symptoms usually undergo aggravation, and 
the remissions become more and more rare and brief. 

Death is either produced by the advance of tuberculous disease in the 
lungs, or by tubercular meningitis ; or the little patient sinks from sheer 
exhaustion under the persistent diarrhoea and the repeated accessions of 
peritoneal disease. 

Symptoms of Tuberculosis of the Mesenteric Glands. — The symptoms of 



DURATION — DIAGNOSIS. 859 

this condition are even less positive ami diagnostic than those of tuber- 
culous peritonitis. So long as the glands remain only moderately enlarged, 
buried as they are beneath the small intestine, it is impossible to detect 
their presence, especially as the absorption of chyle is not materially inter- 
fered with. 

^Ve have already mentioned, moreover, the comparative rarity of symp- 
toms due to the pressure of the enlarged glands upon neighboring struc- 
tures, such as perforation or compression of the intestines, and dilatation 
of the cutaneous veins, or Q?dema. 

The modifications of the size and shape of the abdomen occasionally 
furnish useful information. It is rarely so large and tense as in tubercu- 
lous peritonitis, and its shape is rather globular than oval. 

There is scarcely any tenderness on pressure over the abdomen, unless 
there is some accompanying peritonitis. 

The only really pathognomonic symptom, indeed, is the detection of the 
enlarged glands by palpation. This, however, is far from being possible in 
all cases, even when the bulk of the glands is very considerable, as they 
are frequently covered and concealed by the intestines. 

It is, in fact, only in those cases where the abdomen is supple and relaxed, 
that we can establish the presence of the tumor, which is usually lobulated, 
varying in size from a hen's egg to a large orange, and seated in the neigh- 
borhood of the umbilicus. 

The digestive system here also presents more or less marked disturb- 
ances; the bowels in particular being loose, a condition generally due to 
the existence of tuberculous ulceration of the intestine. 

The general symptoms which accompany tuberculization of the mesen- 
teric glands alone, are often not so marked as when other organs are 
affected ; in fact, MM. Rilliet and Barthez assert that they have not met 
with a case in which this affection, isolated from all others, has produced 
any considerable emaciation. This does not, however, correspond with 
our own observation, since we have met with cases where the interference 
with general ncalth and the attendant emaciation were very marked. 

Duration. — The duration of tuberculosis in children, as might have 
been expected, varies considerably according to the position and surround- 
ings of the patients. In large hospitals, where the children have not the 
advantage of the bast hygienic influences, the majority of cases terminate 
in from 3 to 7 months, though occasionally protracted to upwards of 2 
years. In private practice, on the other hand, many cases of chronic 
phthisis are met with, in which the disease continues for 3, 4, or even 5 
years before producing death. It is extremely difficult to assign any 
probable duration for either tuberculous peritonitis or tabes mesenterica, 
as they can rarely be diagnosed during the early stages of their develop- 
ment. 

Diagnosis. — The danger in regard to the diagnosis of phthi.-is in chil- 
dren is not so much of entirely overhj<jking the nature of the disease, as of 
overestimating its amount. We have already given the reasons why the 
physical signs of pulmonary and bronchial tuberculosis in children are less 
reliable and more difficult to appreciate than in adults. A proper atten- 



860 TUBERCULOSIS. 

tioii to the hereditary tendencies and individual history of the child ; a 
close scrutiny of its physical conformation and development, with an in- 
telligent interpretation of the physical signs, will, however, generally suffice 
to prevent any serious error. 

In the earlier stages of the more acute forms of phthisis, the disease with 
which it is most apt to be confounded is remittent fever ; from which it 
may be distinguished by the history of malarial exposure, by the definite 
commencement of the case, and by the very marked exacerbations which 
occur towards night, attended with high fever, great heat of skin, and con- 
siderable delirium. In its more chronic forms, the diagnosis of pulmonary 
phthisis from chronic bronchitis is often attended with the greatest diflS- 
culty. In fact, the physical signs of the two conditions are frequently so 
entirely analogous, that it is only by the general symptoms of tuberculosis, 
the greater amount of hectic irritation, the more rapid emaciation, and the 
frequent supervention of tubercular deposit in other organs, that a diag- 
nosis can be established. 

We have already dwelt upon the value of abnormal development of 
the abdomen as a symptom of tubercular peritonitis. There are, however, 
many cases of simple functional derangement of the intestines, in which 
no suspicion of tuberculous deposit can be entertained, where this symp- 
tom is also noticed. It is due to this circumstance that tubercular disease 
of the peritoneum and mesenteric glands was formerly considered of such 
frequent occurrence. A careful regard, however, to the age of the patient ; 
for simple distension of the abdomen occurs generally in infancy, whilst 
tuberculous peritonitis is most frequent after the age of 3 years ; and to 
the effects of simple remedies, will usually remove any doubt. 

The cases which are most apt to be confounded with tabes mesenterica 
are those in which abdominal tumors, due to some other cause, are pres- 
ent. Thus, in extensive tubercular deposit in the omentum, we may have, 
in addition to the general symptoms of tuberculosis, a well-defined tumor 
about the middle of the abdomen. The greater degree of tenderness of 
the abdomen, and the mobility in this case, may, however, serve to dis- 
tinguish it. Again, it is not rare to find in cases of digestive derange- 
ment, where irregular action of the bowels with more or less pain may 
have been present, a distinct and only slightly movable tumor in the ab- 
domen, due to the impaction of the intestine with hardened faeces. A 
careful consideration, however, of the position of these masses, which is 
generally in one or the other iliac fossa ; their entire painlessness and 
doughy character upon palpation, and their complete disappearance after 
the administration of laxatives and enemata, will reveal their true nature. 

Prognosis. — The very name of tuberculosis has grown, with only too 
much reason, to be almost synonymous with impending, unavoidable 
death. And yet, while pulmonary phthisis shows the same fatal tendency 
in childhood as in adult life, the prognosis is somewhat less gloomy. For 
not only does well-directed treatment occasionally render the morbid de- 
posits in the lungs in some cases of phthisis, whose existence has been 
proved by the symptoms of the incipient stage, inert and obsolescent ; but 
in rare cases, where the deposit has advanced to softening and destruction 



MODES OF DEATH — TREATMENT. 861 

of lung-tissue, a cure has been stowly effected by the evacuation of the 
softened tubercle and the gradual cicatrization of the cavity. 

In tuberculization of the bronchial and mesenteric glands, moreover, 
numerous cases have been noticed where the glands have undergone com- 
plete calcification, and the progress of the disease has been arrested, 

While, therefore, the prognosis must ever be grave and unfavorable, we 
must bear in mind the possibility of recovery when the hereditary ten- 
dency of the child is not too strongly pronounced, and the actual tuber- 
culous deposit not extensive or rapidly progressing. 

MoDF^ OF Death. — Having thus spoken briefly of the prognosis, a few 
words will sutfice to call attention to the various modes in which phthisis 
brings about a fatal issue in children. 

In the majority of cases, death occurs from sheer exhaustion of the 
powers of life, from impaired nutrition and perverted functions. In a 
few instances of bronchial phthisis, death is suddenly caused by copious 
hieraorrhage, owing to the perforation of one of the pulmonary blood- 
vessels. 

The immediate cause of death is frequently found in an intercurrent at- 
tack of bronchitis, pneumonia, or peritonitis ; while, in other cases, the 
cerebral symptoms which precede the fatal event, show that the mem- 
branes of the brain have become the seat of tuberculous deposit. 

It is not unusual, moreover, whether the original seat of the tuberculous 
deposit have been in the abdomen or thorax, for marked abdominal symp- 
toms to be developed towards the close of the case; the tuberculous ulcer- 
ation of the intestines serving to maintain an uncontrollable and exhaust- 
ing diarrhoea. 

Treatment. — Prophylactic. — In children whose parents are tuberculous, 
and who in early life give evidence of delicate health, the prophylaxis be- 
comes most important. The infant should be kept at the mother's breast 
up to the age of fifteen or eighteen months; but in case the mother be 
herself tuberculous, on no account should she be allowed to nurse the 
child, for whom a healthy wet-nurse should be immediately procured. By 
aiteotion to this precaution, we have succeeded in raising children of tu- 
berculous mothers, who had suckled their previous children and had lost 
them all in early life from tuberculous disease. 

As the child advances in age, every caution should be paid to \Ui food 
and clothing, to securing sufficient exercise in the open air, and free ven- 
tilation in it* sleeping apartment. When the circumstances of the parents 
permit it, it is of the greatest consequence that the child shtndd enjoy the 
benefits of a country life, in some healthy, invigorating atmosphorr, f.r 
four or six months out of every year. 

The child should further be guarded wdulou.-ly from the ailmcni- hm i- 
dent to early life, and esi>ecially from hooping-cough and measles; and 
the slightest disturbance of either the respiratory or dige>«tive functions 
should receive prompt and careful treatment; nor should we be tempted 
to discontinue these efforts, even if pc^sitive signs of tuberculous de|Ki8it 
appear; for the possibility of these deposits in childhood becoming latent 



862 TUBERCULOSIS. 

or being evacuated, and the general health re-established, should never be 
lost siglit of. 

Curative. — Little need be said of the treatment of fully developed tu- 
berculosis in children, since. the same indications present themselves as in 
adults, and call for the same remedies. The most essential points in the 
treatment are attention to all hygienic conditions, careful regulation of the 
diet, and the administration of remedies calculated to improve nutrition 
and primary assimilation. 

It is indeed impossible to overestimate the importance of maintaining 
the appetite and powers of digestion ; and if these show any sign of fail- 
ing, we should resort to some of the bitter vegetable tonics, of which, per- 
haps, the combination of tincture of nux vomica, gtt. ij to v, with the 
compound tincture of gentian, -njjxv to xxx, according to the age of the 
child, is most desirable. On the other hand, if we find reason to believe 
that any remedy we are administering disturbs the nutrition of the child, 
disgusts it, lessens its appetite, or rouses violent opposition at every dose, 
it should be instantly abandoned as producing the very effect we most 
desire to avoid. 

The child should be strongly encouraged to take nourishing food at 
regular intervals, and so soon as any of the articles of its diet become 
unattractive, other preparations of similar nature should be substituted. 
Milk should enter largely into the diet, and ought to be taken at least 
every morning and evening. Tender, finely divided meat should be eaten 
at the midday meal, in such quantities as the digestion will easily bear. 
If marked signs of debility present themselves, a few drachms of good 
brandy may be taken at intervals through the day, with advantage. 

When the stomach does not reject it, there are few remedies whose 
action is more beneficial than cod-liver oil, given in the dose of a tea- 
spoonful or even less, three times a day. In many instances, children 
soon become accustomed to the taste of this substance, and even grow to 
relish it almost as a luxury, and to take it eagerly ; in some cases, how- 
ever, the taste is so unpleasant that the children refuse to take it, and it 
is, therefore, advisable in such instances to prescribe it in the combination 
which we have already recommended, at least during the first few weeks 
of its administration. 

In those cases where it is impossible to administer cod-liver oil internally, 
very good results may often be obtained here, as well as under similar 
circumstances in other wasting diseases of children, by the use of the oil 
by inunction. 

Iron and its various preparations are strongly indicated, and we can 
generally find some of the milder forms which will be readily tolerated. 
In those cases where there is considerable implication of the lymphatic 
glands, the syrup of the iodide of iron appears especially useful, and this 
may be well given alternately or in conjunction with iodide of potassium. 

Sea-bathing is strongly recommended, especially in the tuberculization 
of the glandular system; or when this is not attainable, baths in which 
some tonic drug has been mixed may be used. 

In tuberculous deposit in the peritoneum or mesenteric glands, the diet 



RICKETS. 863 

must be regulated with peculiar care; the most bland, unirritating, and 
digestible food being selected. If, however, despite our pi*ecautions, diar- 
rha?a should make its appeanmce, the various astringents in combination 
with opium should be given freely. The pain in the abdomen, which is 
frequently so severe in these forms of tuberculosis, may be relieved by the 
application of sinapisms, or of warm anodyne poultices, or by gentle fric- 
tion with a sedative liniment. 

When the symptoms of any intercurrent inflammation in- the diseased 
organ present themselves, we must limit our treatment to the application 
of a few cups or leeches over the part, and the administration of a less 
stimulating diet, with some mild febrifuge. When the peritoneum is in- 
volved in the tubercular deposit, and we have reason to fear an accession 
of inflammation of that membrane, there is urgent necessity for the use 
of topical depletion in moderation ; but we must, at the same time, bear 
in mind the cachectic nature of the disease, and refrain from the adoption 
of any depressing plan of treatment. 



ARTICLE III. 

RICKETS. 

DEFixiTioy; Syxoxyms; Frequency. — Rickets is a constitutional 
disease peculiar to childhood, which first manifests itself by various dis- 
turbances of nutrition, and later by a specific alteration in tlie bones. 

This disease has been known under a vast variety of names in many 
diflerent languages ;' almost the only terms by which it is designated by 
English or American authors, however, are rickets and rachitis. 

An idea of the vast importance and frequency of this disease may be 
gained from the statements of some of the recent writers upon this subject. 
Thus Sir W. Jenner, whose lectures upon this subject {loc. cit.) present a 
must original, philosophical, and lifelike description of the disease, speaks 
of it as " without question the most common, the most important, and in 
Its eflects the most fatal of the diseases which exclusively afl'«'ct children." 
Hillier, at the close of an excellent chapter upon rickets (loc. cit.), pre- 
sents a table showing the proportion borne by the number of cases of this 
• the total number of out-patients treiited at the Hospital f«)rSick 
• 1, I»ndon, from which we calculate that of riH,^)'^; children 

treated during thirteen years (1854-66), Dot less than 8419, or 6.5 per 
cent., were rachitic ; and in some years the proportion of f^urh patients 
rose as high as 9 per cent. 

The statistics furni-he^l by other Engli-h writers, a-* (J.'e (ior. cH.), 
Merei, and Ritchie, supp^jrt the view that in all cla.'tsei* of Englinh wjciety 
a notable proportion of the children are rachitic. In the same way, the 



For Synonymy, Me Art. RickeU In Reynoldi's 8y«t. of Med., toI. I, p. 768. 



864 RTCKETS. 



m 



highest German authorities, as Ritter von Rittershain and Henoch, state 
that the proportion of the children treated at public institutions in that 
country, who are found to be rachitic, is not less than 30 per cent. 

Of late years, the attention of observers in this country has been more 
forcibly attracted to this subject, and, as a consequence, the number of 
cases in which the early and less prominent symptoms of rickets are now 
recognized is rapidly increasing. In a paper on this subject by Parry,^ 
which we regard as the most valuable contribution to the literature of 
rachitis which has been made on this side of the Atlantic, the writer states Bj 
that he has been " irresistibly forced to the conclusion that rachitis is 
scarcely less frequent in Philadelphia than it is in the large cities of Great 
Britain and the continent of Europe." We must add that, although, 
judging from our own experience, the above statement is an overestimate, 
the number of cases in which we meet with the early, or even the more 
grave symptoms of rickets, is quite large both in private practice and in 
connection with public institutions. 

The fact that during the past twelve years the mortality returns of this 
city contain but two deaths reported as from rickets, is of little importance, 
since so rarely is it assigned as a cause of death even in Great Britain, 
that the Registrar-General has not found it necessary to devote a column 
of his tables of mortality to the disease. " The secondary diseases," as 
Hillier says, " are recognized, such as bronchitis, collapse of the lungs, 
atrophy, measles, hooping-cough, or convulsions, but the primary disease, 
which renders these secondary diseases fatal, is ignored." 

We shall limit ourselves to an account of the causes, general symptoms, 
and treatment of the disease, with a brief description of the anatomical 
changes in the bones, and the deformities which result, referring the reader 
who desires more minute knowledge on these latter points, to any of the 
elaborate memoirs published on this disease.''' 

1 Amer. Jour. Med. Sciences, Jan. 1872, p. 17. 

2 Bibliography of Kickets. — Shaw, Med.-Chir. Trans., vols, xvii and xxvi. 
Guerin, Mem. sur le Kachitis, Gaz. Med. de Paris, 1839, pp. 443, 449, 481. 
Elsasser, Der weiche Hinterkopf, Stuttgart, 1843. 

Meyer, Miiller's Arch., 1849, p. 358. 

Kokitansky, Path. Anat. (Syd. Soc), 1850, vol. iii, p. 174. . 
Beylard, J:>e Rachitis, etc. (The.se de Paris), 1852. 
Stiebel, in Virchow's Path. u. Ther., Bd. i, p. 527. 

Vogel, Beitrage z. Lehre v. d. Rachitis, Erlangen, 1853; and Diseases of Chil- 
dren (Atner. ed., 18G9), p. 520. 

Kolliker, Human Histology (Syd. Soc), 1853, vol. i. p. 352. 

Bouvier, Lect. Clin, des Malad. Chron. de I'Appar. Locom., 1856, p. 265. 

Mauthner, (Estr. Ztschr. f. Kinderhlk., vol. ii, 11, 1857. 

Copland, Diet, of Pract. Med., 1858, vol. iii, p. 643. 

Friedleben, Beitr. z. Kenntniss wachs. u. rachit. Knochen, 1860. 

Jenner, Med. Times and Gaz., 1860. 

Bouchut, Mai. des Enfants, 4eme ed., Paris, 1862, p. 825. 

G. Ritter von Rittershain, Die Path. u. Ther. der Rachitis, Berlin, 1863. 

For.ster, Handb. d. Path. Anat., 2te Aufl,, 1863, Bd. ii, p. 917. 

Virchow, Cellular Path. (Chance's Trans., Amer. ed.), 1863, p. 476. 

Trousseau, Clin. MeJ., 2eme ed., 1865, t. iii, p. 453. 



CAUSES. 865 

Causes. — Age. — Rickets is esseutially a disease of childhood, and indeed 
may make its appearance during early infancy. There are also a few 
cases on record which show that it may, although rarely, occur in the 
fivtus before birth. It frequently may be detected during the first six 
months of extra-uterine life. Gee has noticed positive bcadirg of the 
ribs at the third and fourth weeks, and Parry at the sixth week after birth. 
The age at which it ceases to be frequent foe rachitis to begin is variously 
estimated. We have observed a number of cases where the earliest symp- 
toms were detected during the second year ; and we should be inclined to 
:'.-- _Mi as the limits of its most frequent occurrence the second or third 
!!; all to the close of the second year. It grows rarer after this latter 
date, and many high authorities unite in saying that it never comes on 
atter the completion of the first dentition in a child hitherto perfectly 
healthy. Considerable difference of opinion exists upon the question 
whether rickets is hereditary or not; but there seems no evidence to show 
that it ever is so, in the sense, for example, in which infantile syphilis is 
hereditary. There can, however, be no doubt as to the great influence ex- 
ercised by the health of the parents upon the development of the disease. 

It is stated by some authors that too early marriages, or marriages be- 
tween relations, and chronic tuberculosis or constitutional syphilis of the 
father, predispose to it. These causes are, however, of doubtful power ; 
and certainly are iuo|K.'rative as compared with the very positive influence 
exercised by the condition of the mother. Thus, it is well ascertained, that 
whatever tends to induce debility and anicmia in the mother, as too fre- 
quent pregnancies or prolonged lactation, renders it probable that her next 
born children will be rickety. Thus, Jenner states that it is very common 
for the first, or the two or three first born children, to be free from any 
sign of rickets, and yet for every subsequent child to be rickety; which he 
explains by the fact, "that among the poor the parents are generally 
worse fefJ, worse clothed, and worse lodged, the larger the number of their 
children; and among the rich and pwr alike, the larger the number of 
children, the more has the mother's constitutional strength been taxed, and 
the more likely is she to have lost in general power." {Loc. dt.) 

In addition to the tendency derived from the mother, there are numer- 
ous causes acting directly upon the child, which strongly predispose to the 
disease. These will be found to be nearly the same as those which favor 
the development of tuberculosis. Thus, premature weaning, and the sub- 
stitution of improper fowl for the mother's milk ; or, on the other hand, 
the continuance of suckling long after the pro[>er period for weaning, and 
after the mother's milk has deteriorated in quality and become insufficient 

Wwl, Din. of Children (4th Amer. cd.), 18«6, p. 688. 
W. .Vilken, Art. RickcU in Keynold»'H Sy»t. of Med., 1868, vol. i, p. 708. 
Hillicr, Di» of Child. (Amer. ed.), 1H68, p. 92. 
S. Gt-e, St. Bnrth. Ho«p. R^p., vol. iv, 18»i«. p 69. 
Niemoyer, Pract Med. rAmcr. ed.), 1869, vol. ii, p. 607. 
.Incobi, Amer. Jour, of Ohj«t«flric«, Nov. 1870, p. 485. 
Parrot, Arch, de Phyn., February, IH76, p. \S4. 
yioijTc, London Lancet, Augu«t 26lh, 1876. 

66 



RICKETS. 

and unwholesome ; or the use of indigestible, or of poor, scanty, and innu- 
tritions food at any period during early childhood, are all potent causes of 
rickets. So, too, many of the acute and chronic diseases of children, which 
impair assimilation and nutrition, as entero-colitis ; and all such depressing 
influences as impure water, foul air, poor ventilation, small, damp, and 
dirty habitations, may be classed among the predisposing causes. 

The marked alterations and deformities of the bones, which are so char- 
acteristic of rickets, are not developed until after a more or less marked 
cachectic state of system has persisted for a time, varying from a few weeks 
to several months. 

During this initiatory stage, the most marked symptoms are connected 
with the digestive system. The appetite may remain good or grow capri- 
cious ; and the bowels are irregular, though for the most part of the time 
there is diarrhoea, with stools which are at first greenish and mucous, sub- 
sequently serous, watery, of a brownish or slate color, and horribly offen- 
sive. If this chronic intestinal catarrh be but slightly marked, the child 
may retain a good deal of its fat, though frequently there is extreme ema- 
ciation. 

The head is frequently bathed in profuse perspiration, which occurs 
especially during sleep, but also after any exertion, or even while the child 
is lying quiet. The skin of the trunk and extremities is hot and dry, and 
even the lightest covering seems oppressive to the little patient ; so that 
there is a tendency to get rid of all the bed-clothing at night. 

Another symptom which makes its appearance in a certain proportion of 
cases, but not so constantly as the digestive disturbances, local sweatings, 
and restlessness at night, is general soreness and tenderness of the body, 
with pain on movement : when this is marked, the child dreads to be 
moved or even touched, cries if its limbs be pressed firmly, and will lie 
almost motionless for hours. According to Parry {Iog. cit.), this symptom 
is associated with the commencing bone changes, so that it properly be- 
longs to the early part of the second stage. 

If the disease begins before the completion of primary dentition, the 
development of the teeth is always impeded, and they are not only cut 
late, but either decay or fall very early from their sockets. The urine 
does not present any constant alteration, but in a certain proportion of 
cases the amount is increased, and there is an excess of the phosphatic 
salts, while in other instances excess of some free acid, said to be usually 
lactic, has been detected. The mental condition in rickets has been vari- 
ously described ; some authors regarding the intelligence as precocious, 
owing probably to the isolation of the patient from other children, and his 
constant association with his elders ; while others assert that there is an 
actual deficiency in intellectual capacity and power. At a somewhat later 
period of the disease, the child acquires a peculiar staid and sedate aspect, 
which, when associated with the unusual breadth and squareness of the 
face, imparts a strange expression of age. 

According to lloger and Rilliet, a blowing murmur may frequently 
be heard over the anterior fontanelle in this disease, synchronous with 
the arterial pulse. As, however, this murmur is to be heard in other 



SYMPTOMS OF STAGE OF DEFORMITY. 807 

conditions, ami is often absent in cases of rickets, it cannot be consid- 
eretl as a sign of any positive value. The causes which appear to in- 
tensify it, are the aniemic state of the blood and the patency of the 
anterior fontanelle; yet Hillier states that he has found it present in thir- 
teen, and absent in twenty-nine rickety children whose foutanelles were 
open. 

The phenomena above described, when present in tlic same case, may 
certainly be regarded as positively indicative of the existence of this ini- 
tiatory stage of rickets, but they are by no means invaria))ly all present, 
so that it is often impossible to determine the approach of the next stage 
in which the characteristic lesions and deformities of the bones make their 
appearance. 

They are not, moreover, limited to the stage of invasion, but continue, 
with more or less severity, for a varying time after the bone-changes have 
begun. The length of this stage of invasion is exceedingly irregular, and 
the earliest physical signs of bone-change may occur after it has lasted a 
few weeks, or may be deferred for several mouths after the peculiar pro- 
dromic symptoms have been marked. 

Stage of Deformibj. — After the initiatory stage has lasted for a varying 
time, bead-like swellings begin to be noticed at the line of junction of 
the ribs and costal cartilages, which is usually regarded as the earliest 
lesion of the bones, and of the epiphyses and shafts of the long bones of 
the upper and lower extremities, giving in these latter places, as at the 
ankles and wrists, a peculiar knobby double-jointed appearance. With 
this, there is such a degree of softening of the bones, that they yield 
readily to pressure. 

Early in this stage the presence of craniotabes, or " soft spots " in the 
'ccipital bone, may often be detected. Indeed, in some instances this ap- 
pears to be the first recognizable bone lesion. 

If the disease reaches this stage before the child ha.s begun to walk, there 
may be no deformity of the lower extremities whatever ; but in cases where 
the little patient has already been walking about, the femora bend so that 
they become markedly convex forwards ; the tibiie bend in the same for- 
ward direction, while the knees may be bent inwards, thus giving to the 
legs a series of curvatures. The forward curvature of the femora may in- 
deed be profluced before the child walks, simply by the weight of the legs 
and feet, which hang pendent from the knee-jointa as the child sits in its 
mother'i lap or on a chair. 

The bones of the upper extremities also share in these deformities ; thus 
the humeri Ijend at the p<^>int of insertion of the deltoids, from the weight 
of the arms when raised by the action of these muscles; and both the hu- 
meri and the bones of the forearms become bent, from the pressure which 
the child makes on its open palms to assist itself in sitting up. 

The clavicles are very constantly deformed, and present a double curva- 
ture ; one curve being forwards and somewhat upwanis, and seated just 
outside of the attachment of the stemo-cleido-niastoid muscle, the other 
being backwards, and seated about half an inch from the acromio-clavicu- 
lar articulation. 



868 RICKETS. 

By far the most important deformities, however, are those presented by 
the head, spine, thorax, and pelvis. The peculiarities by which the head 
in rickets is distinguished, are thus described by Jenner : 

1st. By the length of time the anterior fontanelle remains open. In the 
healthy child, it closes completely before the expiration of the second year. 
In the rickety child, it is often widely open at that period. 

2d. By thickening of the bones. This is usually most perceptible just 
outside the sutures, the situation of the sutures being indicated by deep 
furrows. 

3d. By the relative length of the antero-posterior diameter of the head. 

4th. By the height, squareness, and projection of the forehead. The 
first two of these peculiarities of the rickety head are the result of the 
affection of the bones ; the last two are due chiefly to disease of the cere- 
brum. 

Besides this thickening of the edges of the cranial bones, there are 
spots, irregularly distributed, where the bones are so thinned and softened 
that they yield to the pressure of the fingers ; and, indeed, in some cases 
the thinning is so extreme that the pericranium and dura mater come in 
contact. These "soft spots," which constitute the condition known as 
craniotabes, were first observed by Elsasser {loc. cit). 

The nature and mode of their production has been a matter of much 
discussion. By some authorities their rachitic nature has been denied, but 
there seems to us no valid reason for doubting their essential connection 
with the rachitic alterations of the bones. They are usually limited to 
the occipital region, but may rarely be present over the other cranial bones. 
They are never observable save in those parts of the bones which are de- 
veloped from membrane. At first, the spots affected are the seat merely 
of softening, with perhaps some thickening ; then thinning of the bone 
occurs, and subsequently the entire thickness of the occipital bone is often 
removed, causing perforations. These vary in number from one or two to 
as many as twenty-five or thirty. In order to detect them, the skull should 
be carefully examined by fixing the head between the hands, and then 
pressing carefully over the upper part of the occipital region and the pos- 
terior portions of the parietal bones. The diseased spots are felt to be soft 
and easily depressed, and " impart the sensation of an orifice in the bone, 
closed by parchment." It is necessary to use much caution and gentleness 
in making this exaoiination, since any undue pressure may produce severe 
nervous symptoms, even convulsions, according to Niemeyer. It is diffi- 
cult to account for the production of these spots, but the most probable 
explanation is that they are dependent upon the prolonged pressure upon 
the softened bone, caused by the head resting on the pillow on one side, 
and by the counter-pressure of the brain on the skull on the other. 

The curvature of the spine varies according as the child is able or un- 
able to walk. In the latter case, there is a posterior curvature of the spine, 
beginning at the first dorsal, and extending to the last lumbar vertebrae; 
while if the child is able to walk, this posterior curvature is limited to the 
dorsal region, but is combined with an anterior curvature in the lumbar 
region. The cervical anterior curve is increased, and consequently the face 



CAUSES. 869 

is directed upwards, and the head falls backwards, and being unsupjioitod, 
owing to the muscular debility, sways loosely from sitle to side. Jenuer 
points out that these curvatures may readily be distinguished from angular 
curvature, by the fact that the weight of the legs will usually remove them 
if the child be held by the up}>er part of the trunk, especially if the phy- 
sician at the same time raises the lower limbs with one hand, and places 
the other on the curved spine. 

The thorax is subject to deformities, which in a practical sense exceed 
all others in importance, owing to the serious interference which they occa- 
sion with the action of the heart and lungs. 

In the first place, owing to the curvature of the spine, the ribs are llat- 
tened laterally, and run forwards more horizontally, so that the lateral 
diameter of the chest is greatly diminished, while the sternum is carried 
forwards, and thus the antero-posterior diameter of the thorax is increased. 
In addition, there is a marked groove on either side of the sternum, ex- 
tending from the first to the ninth or tenth ribs, along the line of junction 
of the ribs with their cartilages. These grooves are produced by the bend- 
ing of the ribs where the dorsal and lateral portions unite; from which 
point they pass forwards and inwards to unite with their cartilages, which 
curve outwards before uniting with the sternum. 

The curvatures and deformities which have been described before this 
are chiefly due to the action of muscles or the weight of dependent parts ; 
but the production of the last-described deformities of the thorax is attrib- 
uted by Jenner chiefly to the atmospheric pressure, which, during inspira- 
tion, causes recession of the most yielding part of the thoracic walls, /. e., 
the softened ribs at the line of junction with their cartilages. In conse- 
quence of the support which the liver, heart, and spleen furnish to the 
ribs corresponding to their position, the groove extends further down on 
the left than on the right side, but is deeper over the fifth and sixth ribs 
on the right than on the left side. 

The pelvis is frequently aflfected in rickets, and the deformities which 
result, on account of the great interference they cause in childbirth in the 
female, rank next in importance to those of the thorax. The rickety 
pelvis is characterized by a shortening of the antero-posterior diameter, so 
that the upper strait a^ssumes an oval form, or is at times heart-shajx;d. In 
extreme instances the sides also approximate, and give to the pelvis a tri- 
angular shape. It is evident that the form will be influcnce<l by a number 
of conditions; as the stage of ossification, an«l the direction in which the 
pelvis is compressed by the spine from above, and the thigh-bones from 
below. 

Partly in consequence of the diminished capacity of the thorax and 
pelvis, partly in consequence of the weakness of the abdominal nnHcIe**, 
the flatulent distension of the intestines, and the enlargement of the liver 
and spleen which are frequently present, the abdomen is unusually promi- 
nent in rickety children. 

During the development of the alterations in the bones, the general 
symptoms before described persist ; the digestion is enfe<;bled, and the stools 
liquid and fetid; the ema'-?'''' " ?nid debility in^Tfa"^' ; thr- rc'spiration is 



870 RICKETS. 

more or less embarrassed by the deformities of the thorax ; the pulse is 
quick, small, and irritable ; the skin hot, excepting on the head and neck, 
where it is still frequently bathed in sweat ; and the general tenderness of 
the body is aggravated. 

In cases where the disease approaches a favorable termination, the ear- 
liest signs of improvement consist in a decrease in the emaciation, debility, 
and suffering ; the stools become more healthy, and the febrile symptoms, 
if any have been present, disappear. 

During this stage of early convalescence, when the children attempt to 
leave the bed and walk about, holding on to the chairs, there is great danger 
of increased curvature and even of partial fractures of the bones of the 
lower extremities. 

When, on the other hand, death occurs during the course of rickets, it 
is rarely from the intensity of the cachexia (which explains the apparent 
anomaly of so fatal a disease being scarcely represented in the mortality 
returns), but from the supervention of some secondary disease. Among 
these, the following are enumerated by Jenner as the most frequent causes 
of death : 

1. Catarrh and bronchitis, which are rendered far more dangerous from 
the mechanical interference with respiration caused by the deformed 
thorax. 

2. Albuminoid (?) infiltration of various organs, especially of the liver, 
spleen, and lymphatic glands. As will be seen by the remarks in the sec- 
tion on morbid anatomy, recent researches make it probable that the en- 
largement of these organs in rickets differs from ordinary albuminoid 
change. This peculiar form of degeneration is not unfrequently developed 
during the course of rickets ; it manifests itself by increased emaciation, 
extreme pallor, occasional oedema and albuminuria, and enlargement of 
the affected organs. 

3. Laryngismus stridulus, which, according to Jenner, is essentially con- 
nected rather with the nervous irritability due to rickets, than with the 
tardy and difficult dentition which is itself but another expression of the 
constitutional disease. 

4. Chronic hydrocephalus. 

5. Convulsions, depending like the laryngismus stridulus, upon the 
heightened irritability of the nervous system. 

6. Persistent and severe diarrhoea, which is probably due in many cases 
to albuminoid degeneration of the intestinal mucous membrane. 

Duration; Prognosis. — The duration of rickets varies so greatly, that 
the disease may be said to present an acute and chronic form. 

When the diathesis is marked, the hygienic conditions of the child very 
unfavorable, and the disease makes its appearance at an early age, its course 
is often very rapid, and death usually follows. When, on the other hand, 
the disease does not begin till late in the second or third year, and when 
the surroundings of the child are more favorable, recovery usually occurs, 
although the disease may last for several years. 

An unfavorable prognosis may be made, then, when the disease begins 
in very early infancy ; when it is attended with marked constitutional dis- 



« 



DIAGNOSIS — MORBID ANATOMY. 871 

turbances; when the deformities of the head and thorax are rapidly aud 
extremely developed: when any of the secondary morbid conditions above 
euumerateil have su|>ervened. When, on the other hand, the reverse of 
these conditions obtains, recovery may be expected, though often only after 
prolonged illness. 

Diagnosis. — It is only during the initiatory stage of rickets, that the 
true nature of the attack is likely to be mistaken. But during this period 
the disease may be confounded either with chronic enterocolitis, or with 
tuberculosis of the peritoneum and intestinal canal. Careful attention to 
the peculiar symptoms of rickets, especially the sweating of the heatl, the 
general soreness and tenderness of the body, and the retardation of denti- 
tion, will, however, lead to a correct diagnosis, even before the swelling of 
the sternal ends of the ribs and of the epiphysial lines of the long bones, 
and the projection of the sternum, remove all doubt as to the nature of the 
case. 

Morbid Anatomy. — The essential lesions in rickets consist of the 
changes in the bones, though there are also certain lesions of the viscera 
which are frequently met with. 

The long bones affected by rickets, in addition to the deformities already 
describe<l, are clumsy, and present marked swellings at the line of their 
junction with the epiphyses. This enlargement is due to excessive devel- 
opment of the spongy tissue in the extremity of the bone and the epiphysis, 
and to marked proliferation of the epiphysial cartilage. The fact that the 
epiphyses widen instead of elongating, is due to the pressure of the super- 
ira(X)sed parts upon the soft proliferating layers, causing them to bulge 
laterally. 

The deposition of calcareous granular particles at the line of ossification 
is also wanting, and the cartilage-cells calcify before the matrix begins to 
03sify, and are converted into bone-cells. 

There is thus excessive formation of the structures which precede or form 
the nidus for ossification, while there is at the same time retardation or in- 
complete performance of that process. 

At the same time, the diaphyses present rarefaction of their tissue, not 
owing to undue softening and removal of old bone, but simply to the fact 
that, while the old layers of bone are consumed by the normally progres- 
sive formation of medullary cavities, the new layers which are produced 
are soft and do not ossify. 

The medullar}- space may reach the line of ossification, or even project 
beyond it into the proliferating epiphysial cartilage. 

The periosteum of rickety bones is usually thickcneil and highly va«- 
cular. 

The bones themselves iKTome 90 soft that they may be bent in any di- 
rection, or even cut with a knife without difficulty. 

Upon section the spongy tissue and the enlarge*! arcolaj arc foun<I filled 
with a crimson pulp, containing bUxKl -globules, a large amount of free fat 
in some cases, and very many round, faintly granular cells, with one or 
two nuclei. According U) Hillier and Parry the reaction of rachitic bones 
U alkaline or neutral. 



872 RICKETS. 

The softening of the bones is fully accounted for by the diminution in 
the proportion of their calcareous salts. Thus Jenner states as the mean 
of the analyses of several observers, that the bones of healthy children 
yield about thirty-seven parts of organic and sixty-three of inorganic mat- 
ters; whereas those of rickety children yield about seventy-nine parts of 
organic to twenty-one parts of inorganic matters. In addition to this, it 
would appear that the organic matters thenaselves undergo change, since 
it has been found by several experimenters that the bones in advanced 
rickets yield neither choudrin nor gelatin on boiling. 

The thickening of the flat bones is caused by the formation of new osse- 
ous layers from the thickened and vascular periosteum, which are especially 
formed at or near the growing margins of the bones, thus accounting for 
the thickened ridges near the sutures of the cranial bones. 

The thickening of the bones of the skull may reach a very high degree ; 
a thickness of I" having been quite frequently observed. There are also 
frequently found on the skull evidences of craniotabes in the form of round 
or oval perforations of the bone, which have been observable during life 
as "soft spots." These perforations are most constant and frequent in the 
occipital bone, and are also found in the parietal bones, or wherever the 
skull has been subjected to pressure. They are surrounded by thickened 
bone, and are produced by the wasting and resorption, under the influence 
of pressure, of the young and unossified layers of subperiosteal formation, 
while the absorption of the inner vitreous table which keeps pace with 
the growth of the brain, proceeds at its usual rate. In number they vary 
from one to twenty or thirty. 

In addition to these changes in the bones, which are the constant and 
essential lesions in rickets, there are certain lesions of the viscera fre- 
quently met with, which depend partly upon the deformities of the skele- 
ton and partly upon the general cachexia. Thus in consequence of the 
peculiar deformity of the thorax, the anterior borders of the lungs be- 
come highly emphysematous, while the band of lung-tissue correspond- 
ing to the deep groove at the sternal end of the ribs is compressed and 
collapsed. 

This peculiar and constantly present strip of collapsed lung, is due to 
the recession of the corresponding part of the ribs during inspiration ; 
but frequently there is also found extensive collapse of the postero-infe- 
rior parts of the lungs from the ordinary causes, bronchitis and impeded 
respiration. Jenner has also called attention to the frequent presence in 
rickets of white spots upon the pericardium, near the apex of the heart. 
These spots thus correspond to the depressed part of the fifth left rib, and 
are in all probability due to the friction of the heart against this hard 
knuckle of bone. 

AVe have before alluded to the enlargement of the liver and spleen 
which appears in some severe cases of rickets. This was formerly re- 
garded as due to albuminoid degeneration, but recent study of such or- 
gans has made it probable that the alteration is a peculiar and specific 
one. 

The differences between this change, and albuminoid (amyloid, of Vir- 



I 



PATHOLOGY. 873 

chow) degeneration were first pointed out by Jenner/ who showed tliat in 
the rickety enlargement, the organs present no reaction with iodine, and 
that in the spleen there is an absence of the peculiar sago-like transturnia- 
tion of the Malpighian corpuscles. Dr. W. H. Dickinson has more re- 
cently examined this subject with care, and has contirmed the view that 
the change in rickets differs both from albuminoid degeneration and from 
the peculiar enlargement of the spleen and lymjihatic glands known as 
Hodgkin's disease. The llvrr in rickets undergt)es an increase of size 
evenly throughout its whole bulk : it becomes pale, containing little blood, 
and is less friable than in health, hard, dense, and elastic. The acini are 
yellowish and are surrounded by a pinkish or grayish line, due to increase 
of the interlobular connective tissue. There is not, however, any bacony 
translucency as in albuminoid degeneration. The spleen is even more 
markedly enlarged than the liver, so that its weight may increase from 
one ounce to half a pound. The organ presents a resilient hardness which 
in extreme cases was compared by Bright to the consistence of a half-ripe 
apple. The color is generally a deep-red or purple, besprinkled with smooth 
white spots, which are enlarged Malpighian corpuscles. The trabeculie are 
much thickened, and there may be also morbid hyperplasia of the cellular 
contents of the meshes, the corpuscles being much crowded together. The 
above change is described by Dickinson, as due not to the presence of any 
formation foreign to the structure of these organs, but to an irregularity of 
growth which alters the natural proportions of their tissues. The epithe- 
lial and corpuscular element is generally increased, while in the liver the 
capsule of Glisson, and in the spleen the trabecular tissue, is abnormally 
developed. There would appear also to be a deficiency of earthy salts in 
these organs. 

In cases where death is directly due to any secondary disease, as bron- 
chitis, intestinal catarrh, or chronic hydrocephalus, there will of course be 
found, in addition, the lesions common to such aflfections. 

Patholckjy. — The description which has been given of the symptoms 
of rickets, clearly establishes the fact that it is a constitutional disease, in 
the same sen.se that .scrofula and tuberculosis are ; and we are conse- 
quently to regard the lesions of the bones as merely a local manifestation 
of the general cachexia. We are unable, however, to advance beyond 
this point, since we are ignorant, not only of the essential nature of the 
vice of nutrition, but rnuallv so of the sjK^cific cause of the chanLres in the 
bones. 

The result ol ctieniH-ai uFialysis has leri to the theory that the disease 
e»entially consists in a rlefioiency of the calcareous salts of the bone.s ; 
and the attempt has been made to explain this deficiency by sup|K)fing 
an excess of lactic acid in the primie viic and blooci, which holds the 
calcareous salts in solution, and prevents them from being deposited in 
the Ixmes. Afiart from the purely hypothetical nature of this supposi- 
tion, and its entire inadecpiacy to explain many of the most serious 
symptoms of rickets, it is to be borne id mind that the excess of free 

1 Medico-Chir. Tram., vol. Hi, 1869, p. 869. 



874 RICKETS. 

acid in the urine is far from being constant, and that the changes in the 
bones are characterized not merely by a deficient deposit of the calcare- 
ous salts, but by their abnormal position, and by all the evidences of an 
active vital process. 

Again the marked vascularity of the bone and periosteum, the rapid 
proliferation of cells, and the pain and constitutional irritation which at- 
tend the disease, have induced others to regard the process as an inflam- 
matory one. But this view is controverted as well by the etiology and 
clinical history of the disease as by its constant anatomical results. 

We can only assume that, i-n consequence either of a special predisposi- 
tion on the part of the tissues themselves, or of an abnormal quantity of 
some stimulus which normally excites the cartilage-cells to undergo di- 
vision, and the periosteum to form new layers of tissue opposed to the 
surface of the bone, there is a morbid activity of these processes resulting 
in an excessive production of preparatory or intermediate structures which 
can only become ossified in an imperfect, irregular, and slow manner. 
The pathological process is thus seen to consist, for the most part, in a 
morbid acceleration of the changes which precede the normal formation 
and growth of bone. 

Treatment. — In cases where there is reason to anticipate the develop- 
ment of rickets, as where the previous children of the mother have become 
rickety, the utmost attention must be paid to the feeding and hygiene of 
the young infant. If careful examination of the mother's milk proves 
that it is unsuitable in quality, a wet-nurse should be immediately pro- 
vided, or if that be unattainable, the child should be fed upon carefully 
selected cow's milk, or upon one of the substitutes for human milk de- 
scribed in the article on thrush. 

So too, after the disease has made its appearance, the most appropriate, 
nutritious, and digestible diet must be selected, care being taken that it 
shall contain a large proportion of animal food. 

The teeth of rickety children are so defective that, when they begin to 
take solid food, it is highly necessary to insure its complete mastication, 
and in cases where the condition of the teeth renders this impossible, the 
meat should be chopped finely and bruised in a mortar. 

The child should be suitably and warmly dressed, and be taken freely 
into the sunlight and open air. The use of salt-water baths, followed by 
active friction of the skin, is also to be recommended. 

During the early stage, when there is marked constitutional irritation 
and pain, the remedies used to relieve these symptoms should be alkaline 
mixtures, such as the effervescing draught or neutral mixture, or magnesia 
(Copland), conjoined with sedatives and tonics. Under no circumstances 
should any depressing plan of treatment be adopted. 

If the digestion be much impaired and diarrhoea is present, the use of 
vegetable tonics, or wine of iron, with mild astringents and antacids, is 
indicated. 

The remedy, however, from which most benefit is usually derived is cod- 
liver oil, and it should consequently be given, in conjunction with iron 
and vegetable tonics, and a small amount of some generous wine, so soon 



I 



CONGENITAL SYPUILIS. 875 

as the nature of the attack is recognized and i^ei-severed with for months, 
or until the disease is overcome. 

The efficacy of coii-liver oil in the treatment of this disease is, indeed, 
so remarkable that all other remedie;? formerly used have been supplanted 
by it. Vogel asserts {op. cit., p. 534) that " rachitis may bo cured by the 
use of cod-liver oil alone, even if the circumstances are in other respects 
unfiivorable." Rickety children usually tolerate the oil well, and even 
become so fond of it that they will willingly take large doses. In some 
cases, however, it disagrees with the stomach and is obstinately refused by 
the children ; and when this happens, so important is the introduction of 
the oil into the system, that we should recommend its use by inunction. 
It very rarely happens, however, that the difficulty in its administration 
cannot be overcome by having the oil prepared in the form of an emul- 
sion, either according to the formula recommended on page 363, or in 
combination with the lacto-phosphate of lime. 

There can be no doubt that when rickets is recognized in its early stages, 
and a suitable medicinal and hygienic treatment promptly instituted, it is 
usually curable in a comparatively short time. When, however, the di- 
athesis is strong and the case overlooked until softening of the bones has 
occurred, and deformities begin to apixar, the treatment must be persisted 
in for many months or even years. In such cases, unfortunately, there is 
only too great probability of the deformities increasing and becoming 
permanent, even if death does not ensue from some intercurrent or super- 
induced disease. 

In order to guard against deformities, the little patient should lie upon 
a firm, smooth mattress, and high pillows should be forbidden. Niemcyer 
recommends that small children should be carried out in a basket ; while 
larger ones should be drawn about in a carriage provided with a mattress. 
Sitting up for any length of time, or attempts at walking, should be pro- 
hibited until the bones have grown firm and inflexible. 

It is not advisable, especially during the earlier stages of the disease, to 
employ any mechanical contrivances to prevent or relieve deformities. 
During convalescence, however, attempts may be made to control the 
deformities by means of leather or pasteboard splints. 

In the treatment of any intercurrent affections it must be remembered 
that we have to do with a condition of malnutrition and enfeebled vitality, 
80 that all remedies of a depressing character must be scnipulously avoided. 



ARTICLE IV. 

COKOEKITAL BYPHILW. 



Infantile syphilis may be either inherited or acquired subserjucnt to 
birth. As, however, the charactere of the latter form do not differ ma- 
terially from those of acquired syphilis in the adult, we shall limit our 
description to bereditar}' syphilis. 



876 CONGENITAL SYPHILIS. 

Careful clinical observation appears to have clearly demonstrated the 
following facts with regard to the transmission of syphilis, in addition to 
the direct contagiousness of both the primary and secondary manifesta- 
tions : 

That the embryo in utero may be infected, if either of the parents have 
constitutional syphilis at the period of conception, no matter whether the 
disease be latent, or if secondary or tertiary symptoms are present. That 
if both parents are syphilitic the child will more surely suffer from the dis- 
ease, and in a more severe form. That if the mother, though healthy at the 
time of conception, contract syphilis during the first six or seven months 
of pregnancy, the child will probably be infected. That when the mother 
infects the embryo, the disease is probably more severe than when the 
father alone is syphilitic, and thus such embryos usually perish, and are 
prematurely cast off by abortion, so that the great majority of children 
with congenital syphilis have inherited it from their father. While the 
last statement is almost universally admitted, there are some authors, as 
Hutchinson,^ who do not admit the greater severity of the disease when 
the mother is the source of contagion. Finally, that a syphilitic father 
may infect the ovum without contaminating the mother's system, though 
the mother may subsequently herself be infected by the embryo. 

In very many cases, though unfortunately not in all, the infected em- 
bryo perishes, and abortion follows. When, however, such infants are born 
living, they usually present no trace of syphilitic disease at birth, but may 
appear well-nourished and healthy. Occasionally, however, children have 
been observed who presented, at the time of birth, copper-colored blotches 
upon the skin, "condylomata, or mucous patches. 

In the majority of cases the first symptoms of the disease appear between 
the fifteenth and thirtieth days after birth, though in many instances also 
during the second month. Thus of 158 cases collected from various sources 
by Diday,^ the disease showed itself — 

During 1st month in ...... 86 

" 2d " 45 

" 8d " 15 

At 4th month in ...... . 

" 5th " 

" 6th " 

" 8th " 

" 1 year, 

" 2 years, ........ 

So that 131 children out of 158 presented evident symptoms of syphilis 
before the end of the second month. 

Among the earliest evidences of the disease are the signs of failing nu- 
trition. The infant, who has grown well, and has been plump and appar- 
ently vigorous for a few weeks, begins to emaciate, the features become 

1 Art. Constitutional Syphilis, in Keynolds's Syst. of Med., vol. i, pp. 297 and 
.315. 

2 Infantile Syphilis (Syd Soc), 1859. 



SYMPTOMS. 877 

pinched, the skin assumes a dry, sallow, shrivelled appearance, and presents 
patches of yellowish-brown discoloration, esjH^cially on the prominent parts 
of the lace; tlie voice becomes feeble, whimpering, and plaintive, and the 
infant soon acquires a remarkable expression of premature old age. 

The appearance of the skin hjis been most minutely described by Trous- 
seau,^ West," Diday, and others, and is in a high degree chamcteristic of 
the disease. 

In addition, however, to these general symjUoms of malnutrition, there 
soon appear the signs of constitutional syphilis, familiarly met with in 
the adult, as well as some which are peculiar to the disease in infancy. 

The symptoms now to be described belong partly to the secondary and 
partly to the tertiary stage, for it is a peculiarity of infantile syphilis that 
the evolution of the symptoms does not follow so orderly a course as in 
syphilis of the adult. The symptoms most frequently met with are certain 
affections of the skin and mucous membranes. Among the cutaneous 
eruptions, pemphigus is one of the most charcteristic. It is also the first 
eruption to appeiir, not rarely being present at birth, and never, according 
to Niemeyer,^ commencing later than the end of the first week of life. 

It usually appears first on the palms of the hands and soles of the feet, 
and may afterwards spread to various parts of the surface. It begins as 
small round spots, of reddish color, which becomes converted in a day or 
two into bulhe, filled with turbid fluid. These burst, leaving irritable ex- 
coriations, and are succeeded by fresh crops of similar vesicles. The early 
appearance of pemphigus is of most fatal import ; though in some cases 
recovery gradually occurs in the course of a few weeks. The other forms 
of eruption usually occur after the general symptoms of malnutrition, 
above described, have appeared. At times the eruption consists of sharply 
defined patches of roseola or erythema of small size, of coppery or yel- 
lowish-red colof, not disappearing upon pressure, and occurring usually 
Uf>on the abdomen, the inner surface of the thighs, or the lower part of the 
thorax. 

In other ca.ses, the eruption assumes a papulated form, the papules being 
quite prominent, and usually presenting a superficial desquamation. A 
form of acne, attended with the appearance of indurated pustules which 
leave little depressed cicatrices, is not unfrequently met with ; and so, also, 
vesicular and pustular eruptions occur in a good many cases. The most 
frequent of these eruptions is unquestionably the maculated form ; while 
dry, scaly eruptions in particular are quite rare in infantile syphilis. In 
most ca.«es the specific character of the eruption is manifested by the pecu- 
liar coppery color of the macula, or of the inflamed base of the papule, 
vesicle, or pustule. In other instances the specific character of the erup- 
tion must be inferred from the coexistence of other raanifestations of con- 
stitutional syphilis. 

The most frequent of these, next to the cutaneous eruptions, are the 

1 Clin. MM., 2^me ed , 1866, t. Hi, p. 291. 

« Di». of Cfiildrun Mlh Am. ed.). 1806, p. 677. 

» Textbook of Pract. Med (Am. Iran*.), I860, vol. ii, p. 706. 



878 CONGENITAL SYPHILIS. 

affections of the mucous membranes. Thus, coryza, of a serious and most 
obstinate form, is one of the most constant symptoms met with, and presents 
here all the characters fully described in our article upon that subject. 
The nasal raucous membrane is so much swollen that breathing and nursing 
are seriously interfered with. There is a profuse discharge from the nostrils, 
either of a thin, irritating fluid, which flows over the lip and excoriates it, 
or of a thicker pus, which tends to concrete and form thick, discolored 
crusts. The obstruction to respiration, and the accumulation of secretion 
in the nasal cavities, gives rise to a peculiar snorting or snufiing quite 
characteristic of the disease. 

There is apt to be, at the same time, a superficial diffuse inflammation 
of the mucous membrane of the mouth and throat, which may extend into 
the larynx, causing, in conjunction with the coryza, great alteration in the 
cry or voice, which is hoarse, and haS been under such conditions com- 
pared by West to the sound of a child's penny trumpet. 

Despite the severity and obstinacy of the coryza, there comparatively 
rarely occurs any ulceration of the mucous membrane, or necrosis of the 
nasal bones, or of the hard palate. In a few cases, however, we have ob- 
served depression of the bridge of the nose in consequence of the destruc- 
tion of the nasal bones and perforations of the septum between the nostrils 
or of the hard palate, and West records a case in which there was necrosis 
of the hard palate in a young infant. 

Another very frequent symptom is the formation of rhagades or fissures 
at the junction of the mucous membranes and skin, as on the lips, and at 
the verge of the anus. These rhagades bleed upon any stretching of the 
parts, and by their laceration so much pain is caused that, when the mouth 
is affected, the child dreads to smile, talk, or suckle ; and when they are 
seated on the anus, defecation is attended with extreme suffering. Occa- 
sionally rhagades form in the skin in the flexures of the joints, and especi- 
ally in those of the fingers and toes. 

Condylomata are also frequently present, and, like the rhagades, are 
most frequent at the orifice of the anus and mouth, though they may also 
form elsewhere upon the skin, as upon the vulva, between the scrotum and 
thighs, in the axillae, and behind the ears. 

In consequence, probably, of the softening and ulceration of these 
growths, large, sinuous, irregular ulcers may form in such positions, ex- 
tending fi)r some distance into the surrounding skin. 

In a few cases, iritis occurs ; and so too the deeper seated tissues of the 
globe, as the vitreous humor, retina, or choroid, may become inflamed. 

Death very frequently ensues before the end of the first year, either in 
consequence of the severity of the coryza and the inability to nourish the 
little patient, or in consequence of the profound cachexia and anaemia, or 
the development of some of the visceral lesions, to be hereafter described. 
When, however, owing to judicious treatment, or the comparatively slight 
development of the early symptoms, the child survives, the disease fre- 
quently subsides about the end of the first year ; but often, after remaining 
latent for a variable time, reappears in the form of tertiary symptoms. 
According to Hutchinson, this tertiary epoch may begin at any period 



SYMPTOMS. 879 

after the fifth year, but is commonly delayed till at or noar tlie periiul of 
puberty. In addition to the traces which may remain of the earlier symp- 
toms, such as little pits aud scai-s upon the skin, alterations in the form" of 
the nose from long-standing nasal obstruction, or actual disease of the nasal 
bones, there are several very characteristic symptoms amongst the later 
manifestations. 

Among these is a peculiar alteration of the permanent incisor teeth, first 
described by Mr. Jonathan Hutchinson. Although we are not altogether 
disposed to attach the overpowering weight which Mr. Hutchinson does to 
the evidence furnished by this altenition of the teeth, of the existence of 
inherited syjihilis, there is no doubt that it is an important sign, and we, 
therefore, quote in full his description of it {loc. city p. 317) : 

" In the;?e patients (those suffering with inherited syphilis), it is very 
common to find all the incisor teeth dwarfed and malformed. Sometimes 
the canines are afi'ected also. These teeth are narrow and rounded, and 
peg-like; their edges are jagged and notched. Owing to their smallness, 
their sides do not touch, and interspaces are left. It is, however, the 
upper central incisors which are the most reliable for purposes of diagnosis. 
"When the other teeth are affected these very rarely escape, and very often 
they are malformed when all the others are of fairly good shape. The 
characteristic malformation of the upper central incisors consists in a dwarf- 
ing of the tooth, which is usually both narrow aud short, and in the atroj)hy 
of its middle lobe. This atrophy leaves a single broad notch (vertical) in 
the edge of the tooth, and sometimes from this notch a shallow furrow 
passes upwards on both the anterior and posterior surface nearly to the 
gum. This notching is usually symmetrical. It may vary much in degree 
in different cases ; sometimes the teeth diverge, aud at others they slant 
towards each other. In a few rare cases, only one of the upper central 
incisors is malformed, the other being of natural shape and size. It is 
only in the permanent set that such ix'culiarities are to be observed; the 
first set are liable to premature decay, but are not malformed." 

Another valuable symptom of inherited syphilis at this stage, and one 
which never occurs in acquired syphilis, is a [)eculiar form of keratitis, or 
inflammation of the cornea, which has been termed interi<tHial or i<y})hililic. 
It also is usually symmetrical, and is attended by opacity of the corneie 
from the formation of lymph in their substance. The inflammation usu- 
ally subsides in a few weeks or months, leaving slight cloudy opacities here 
and there in the substance of the cornea. 

Occasionally also there are symptoms indicative of grave visceral dis- 
ea«e. The liver and spleen may be found enlarged and firm, and in such 
ca.«e8 aacites is not rare. So, too, afliections of the nervous system, usually 
liroitefl to a single pair of cerebral nerves, as the auditory, and caur^ing 
deafness, or the optic, and canning amaurosis, are met with in some in- 
stances. 

P2ven now markefl disease of the b<mes iw rare, though nodes quite fre- 
quentlv form upon the long bones ; and, in mjme few cases, the disease 
breaks out in the form of destructive lupus, or of serious disease of the 
bony tissues. 



880 CONGENITAL SYPHILIS. 

Morbid Anatomy. — The principal lesions found in the victims of in- 
herited syphilis, are in connection with the liver and lungs ; more rarely 
other organs, as the brain or thymus gland, present evidences of disease. 
The liver is at times enlarged, rounded, and indurated, apparently the 
result of diffuse subacute hepatitis, or of infiltration of the organ with the 
peculiar albuminoid substance, called "amyloid," by Virchow. It is com- 
paratively rare in children to find gummy tumors developed in the sub- 
stance of the liver, with thickening and cicatricial puckering of the cap- 
sule, as are so often met with in visceral syphilis in adult life. 

In the lungs, gummy tumors of various sizes form, and usually present 
cheesy degeneration of their central portion ; and there is at times also a 
form of consolidation, called by Virchow " white hepatization," which de- 
pends upon chronic catarrhal pneumonia, with infarction of the air-vesicles 
with epithelial cells, in a state of partial cheesy degeneration. 

More rarely, gummy tumors have been found in the substance of the 
brain. The thymus gland is occasionally the seat of suppurative inflam- 
mation, so that, on section, abscesses may be detected in the substance 
of the organ. Of course in cases where periostitis, with the formation of 
nodes, has been present, the ordinary appearances of such lesions will be 
observed. 

Diagnosis. — During the presence of the early symptoms, the diagnosis 
is usually made with ease, by observing the presence of pemphigus soon 
after birth ; of other eruptions, with copper-colored discoloration of the 
skin, appearing a few weeks later; of condylomata and rhagades; and of 
coryza, stomatitis, and laryngitis. The general symptoms are also pecu- 
liar, especially the physiognomy and the discoloration of the skin. And 
we should, in addition, endeavor to confirm our suspicion by obtaining a 
clear history of the parents' condition at the time of conception. 

During the later periods of the disease, at or after the period of puberty, 
the diagnosis is no less important, and far more obscure. We must now 
rely upon the history of the case, upon the condition of other children of 
the same family, upon the detection of traces of the earlier symptoms, 
upon the presence of the peculiar alteration of teeth described by Hutch- 
inson, of interstitial keratitis, of nodes, or of a symmetrical affection of 
some of the cranial nerves. 

In deciding between the inherited or acquired nature of any case, the 
points which will aid us are the existence of primary disease of the mother 
at the time of delivery (which is rare, and can rarely be discovered even if 
it have been present) ; the existence of secondary contagious symptoms on 
either the mother or the nurse who suckled the infant ; the presence of 
notched incisor teeth or of interstitial keratitis, which are peculiar to the 
inherited form ; and the symmetrical distribution of all the secondary and 
tertiary manifestations, which is asserted by Hutchinson to be also an at- 
tribute of inherited as distinguished from acquired syphilis. 

Prognosis. — The most unfavorable conditions in inherited syphilis are, 
the infection of both parents ; the appearance of the disease soon after 
birth, especially in the form of pemphigus; and the occurrence of rapid 
and extreme emaciation. On the other hand, if the father alone has sec- 



TREATMENT. 881 

ondary symptoms, and those of a mild character ; if the disease do not 
make its appearance till the third or fourth week; if the general nutri- 
tion is not greatly impaired, and if proper treatment can be imniediatoly 
instituted, the prognosis is favorable, at least as regards preservation of 
life. 

Treatment. — If the previous children of a mother have proved syph- 
ilitic, it is well to subject her to a mild mercurial course during her preg- 
nancy. 

In the treatment of the infant, every care must be paid to supporting its 
strength by the most nutritious diet, if it is unable to suckle the mother. 
It is, however, improper to employ a wet-nurse, on account of the danger 
of her being infected by the child. 

In regard to medicinal treatment, the use of mercury is universally 
recommended during the presence of marked symptoms. The mercurial 
may be given either in the form of hydrarg. cum creta ; calomel ; or 
bichloride of mercury, in solution in some aromatic water, or in syr. 
-arsa?. comp.; or, finally, it may be introduced into the system in the 
lorm of mercurial ointment by inunction. The most convenient mode of 
introducing it in the latter form is by smearing a flannel roller with mer- 
curial ointment, and binding it around the child, whose movements cause 
its speedy absorption. 

The dose of the mercurial should be small, and it is to be continued 
-teadily, though with caution so as to avoid producing salivation, until a 
lecided improvement in the symptoms manifests itself. During its admin- 
istration it will frequently have to be temporarily discontinued, on account 
of gastro-intestinal irritation. 

So soon as the ni,ercury is stopped, we should order the iodide of potas- 
sium or iodide of iron, either one or both together being employed, accord- 
ing to the toleration of the stomach. 

We should also recommend the use of cod -liver oil, and some prepa- 
ration of cinchona, from an early period in the case; and even when 
the child suckles, a certain amount of Liebig's cold extract of meat, or of 
raw beef scraped finely and given as directed at page 410, should be ad- 
ministered. 

The best local application to the sores is black-wash, though the con- 
dylomata usually require to be touched occasionally with solid nitrate of 
silver. 



66 



CLASS VII. 

DISEASES OF THE SKIN. 

INTRODUCTORY REMARKS. 

It will be observed that, in regard to some of these affections, we have 
altered the arrangement which was adopted in the earlier editions of this 
book, while retaining the same general divisions of skin diseases : rashes, 
papules, vesicular, pustular, and squamous affections. For although none 
of the new classifications recently devised, some of them based upon the 
anatomical element of the skin affected, others upon the nature of the patho- 
logical process present, and others still upon the clinical relations of the 
various diseases, appear to us completely satisfactory ; still the more rigid 
study of skin diseases has rendered necessary the removal of a number of 
eruptions from the classes where they were formerly placed. We follow 
then the example of Wilson, who retains the original classification of 
Willan, modified and expanded, however, so as to harmonize with the 
results of more recent observations. 

The class which will be found to have been most changed is that of vesic- 
ular diseases, of which eczema, a disease formerly defined to be charac- 
terized by the presence of vesicles, was the type. It was long ago evident, 
however, that this was not a strictly correct definition, since in many cases 
of eczema, other elements of eruption besides the vesicles were present. 
And, accordingly, the term eczema is no longer restricted to a purely vesic- 
ular eruption, but is erected into a generic title for all affections which are 
characterized by redness, itching, infiltration of the skin, exudation on its 
surface, and the formation of crusts, whether the elementary lesion be an 
erythematous rash, a papule, a vesicle, or a pustule. In accordance with 
this, as will be seen more in detail under the head of eczematous affec- 
tions, this class includes many cases of some affections, as impetigo, which 
were formerly classed among the pustules, and of others which were in- 
cluded among squamous diseases. 

It would be worse than useless in a work like the present, which is neces- 
sarily restricted within certain limits as to size, to attempt a full descrip- 
tion of all the diseases of the skin to which children are subject. Such a 
course would compel us to devote to more important matters than the af- 
fections of the skin, a much smaller proportion of space than they require 
and deserve. We shall therefore select only those cutaneous diseases oc- 
curring in early life, which are most important either from their frequency, 



ERYTHEMA. 883 

or because they present in children some particular aspects or peculiarities, 
which make it necessary that they should be studied separately iroiu the 
same maladies in adults. Moreover, we shall treat of each one as it comes 
before us with greater or less copiousness of detail, according to its respec- 
tive consequence to the medical practitioner, eschewing carefully any use- 
less detail in regard to the more unimportant kinds, but endeavoring anx- 
iously to describe with accuracy the history, diagnosis, and treatment, of 
fiuch as demand a greater degree of consideration. 



CHAPTER I. 



BASHES. 



ARTICLE I. 



ERYTHEMA. 



Definition; Frequency; Forms. — Erythema is a non-contagious ex- 
anthem, characterized by a slight and superficial redness of the skin, ap- 
pearing in patches of irregular form and uncertain extent. It may or may 
not be preceded by or attended with signs of constitutional disorder. It is 
quite 2i frequent affection in some of its forms. 

We shall describe three /on/j,<f of the disease, restricting ourselves, as we 
have already said that we should, to those which seem particularly im- 
portant iu infancy and childhood. These forms are Erythema Fugax, 
Erythema. Intertrigo^ and Erythema Nodosum. 

Erythema Ficjax. — This form of erythema occurs chiefly in the course 
of various acute internal inflammations, and especially those which occur 
during dentition. It may occur during high febrile reaction brought on 
by any cause, especially in children having an active cutaneous circula- 
tion. We have obsers^ed it several times in the loeal inflammations ac- 
companied with great disturbance of the circulation, and particularly in 
cases of severe catarrh occurring during dentition, and in attacks of severe 
simple angina. In these cases it appeared in the form of a bright red 
rash, rf>» uibling ver}- much a mild scarlatinous eruption. It was seated 
upon the upper part of the front of the thorax, and u|>on the outer surfaces 
of the arms. The reti flush disappeare<l readily under prcissure, and flashed 
back the moment the pressure was reraove<l. There was no swelling what- 
ever attending it, and the color was never so bright as that of a severe 
scarlatina, nor .«o deep as that of erysipelas or roneola. It lasted only a 
few hours or half a day, and then disappearecl without desquamation. 

The chief pf>int of interest iu regard to this form of erythema, as it has 
come under our notice, has been the diagnosis between it and scarlet fever. 



884 ERYTHEMA. 

This is to be made out only by recollecting that it has made its appearance 
in the course of another disease, while the child is already suffering under 
some kind of sickness, which is not generally the case with scarlatina ; by 
the less scarlet tint of the eruption, its more superficial character, and more 
limited extent; and lastly, by its short duration. 

Erythema Intertrigo. — This form of erythema was for a long time, 
and is still by some, known by the single name of intertrigo. It occurs 
on the portions of the body exposed to friction by the contact of opposite 
surfaces, and to irritation from the passage over, or retention upon them, 
of the urinary secretion or the fecal discharges. The most common seats 
of it are, therefore, in the folds of the skin about the neck, in the axillae, 
the groins, about the anus, in the cleft of the nates, and on the inside of 
the thighs. 

As it appears in the creases of the skin about the neck, or in the axillae, 
it may be a mere red blush lasting a few days, and then disappearing ; or, 
after presenting this appearance for a short time, the inflammation may 
become much more intense, and occasion an excoriated condition of the 
surfaces attended with the discharge of a serous or a sero-purulent fluid ; 
or, lastly, the inflammation may run into veritable ulceration, giving rise 
to extensive and very painful ulcers occupying the depth of the crease, 
presenting abrupt and jagged edges, and discharging very considerable 
quantities of pus. In these latter forms of the eruption it must be regarded 
as a true eczema, and, indeed, this form of erythema has been by some 
authorities transferred to the group of eczematous affections, under the 
name of eczema erythematosum. In one child, two months of age, of 
delicate constitution, and imperfectly supplied with food, we saw the last- 
described form of the disease occupying at the same time the groins, the 
axillae, and the folds of the neck. The attack lasted two weeks, and very 
nearly proved fatal from the violent suffering it caused. In another child, 
not quite a year old, who was teething, it presented these characters in the 
neck and axillae, while in the groins it was much less severe, the latter 
parts being merely excoriated. 

Infants attacked with severe diarrhoea, with dysentery, or entero-colitis, 
and especially with that form of entero-colitis which so generally accom- 
panies thrush, are very apt to have an erythema of the nates, genital parts, 
and the internal surfaces of the thighs. So common, indeed, is this occur- 
rence that M. Valleix regards erythema of these parts as an almost con- 
stant accompaniment and even precursor of thrush. For our own part 
we have very often met with it in cases of diarrhoea in infants, even in 
those of very moderate severity, but we have never seen it precede the 
appearance of the intestinal disorder. 

This form of erythema begins as a simple redness of the skin about the 
anus, between the buttocks, about the genital parts, and over the inside of 
the upper parts of the thighs. In a mild case of diarrhoea, and in a child 
properly cleansed after each evacuation by stool or urine, it will go no 
further than this : but in a severe attack of inflammatory diarrhoea, at- 
tended with frequent acid stools, and in a case in which proper cleanliness 
is not attended to, the long-continued contact of the discharges and soiled 



DI A GNOSIS. 885 

napkins will often cause the erythema to assume very distressing features. 
The rednesj? extends in such instances along the legs to the feet ; small 
papules, more or less numerous, make their appearance upon the inHamed 
skin ; the^ie are converted into pustules and then into ulcerations, and if 
the case goes on unchecked, the ulcerations become larger, run together, 
and present raw, deep red, and bleeding surfaces, sometimes of consider- 
able size. Very often the ulcerations present a grayish plastic exudation 
upon their surfaces. When these conditions present themselves, the case 
has passed into an exudative form, and is properly to be regarded as an 
eczema papulosum or pustulosum. After cicatrization there remain, at 
the points where the ulcerations had existed, reddish and copper-colored 
spots, which do not disappear for a considerable length of time. This form 
of erythema rarely ceases entirely until the diarrluva which has occasioned 
it has itself been cured. 

Kkvthema Nodosum generally occurs in feeble and delicate children. 
We have never met with it under five years of age. It may develop itself 
upon different parts of the body, but occurs in by far the greater part of 
the cases on the fore part of the legs, or over the anterior edge of the tibia. 
We have only twice seen it elsewhere, and then it was situated upon the 
outer surfaces of the arms and forearms. It is preceded usually for several 
days by general indisposition, by lassitude, thirst, loss of appetite, and some 
feverish ness. It appears in the form of red spots of an oval shape, some- 
what elevated in the centre, and which increase gradually in size. After 
a short time these patches become decidedly elevated above the surround- 
ing surface, and in passing the hand over them they give the sensation 
of n(xlosities. They increase gradually in size, so as to measure from a 
few lines to an inch or an inch and a half long, by half an inch or an 
inch broad, when they present the appearance of reddish tumoi*s, somewhat 
painful to the touch, and having an obscure feeling of fluctuation, as though 
about to suppurate. This, however, they never do, but after a short time 
they diminish in size, their red color changes into a bluish or livi<l tint, 
they soften, and finally disappear entirely in about twelve or fifteen days. 
We have met with five well-marked cases of this disease. Three occurred 
in girls between six and twelve years of age, and two in boys of the same 
age. They all appeared to depend on derangement of the digestive func- 
tion, attended with a somewhat impoverished state of the blood, and gen- 
eral debility. 

DiAGXOSir*. — The only disorders with which erythema could be con- 
founded are erysipelas, roseola, or scarlatina, and this could happ«Mi only 
in regard to the erythema fugax. From erysi|)elas it may be <li.>iingui.-iied 
by the superficial character of the eruption, the absence of swelling and of 
smarting and burning pain, and by the slighter severity and much shorter 
duration of the symj'toms in erythema. Another important feature is the 
peculiar, abrupt, welUlefined, and .slightly elevated margin which marks 
the edge of the erysipelatous rash, and which <locs not exist with the same 
distinctness in erythema. Lastly, the singular regularity observed by 
erysipelas in its gradual extension from place to place, is alt/)gether unlike 
the march of erythema, which shows itself suddenly, or in a few hours, 



886 ERYTHEMA. 

over large surfaces, and, after lasting some hours or a few days, quickly 
disappears. 

In roseola the peculiar deep rose-tint of the rash will serve to distinguish 
between it and the lighter red tint of erythema. 

The mild character of the general symptoms, and the absence of throat 
affection in erythema, will prevent any one who is careful from mistaking 
the disease for scarlatina. 

Erythema intertrigo cannot be mistaken for any other disease, and if 
the course and peculiar local characters of erythema nodosum be borne 
in mind, it also may be easily recognized. The only thing with which 
the latter might be confounded is phlegmonous erysipelas, but if the mild 
character of the general symptoms in erythema nodosum, the distinctly 
circumscribed form of the tumors, and the fact that the disease never ter- 
minates by suppuration, are recollected, there need be no difficulty in 
making the diagnosis. 

Pkognosis. — Erythema is a very mild disorder in a large majority of 
the cases. The only conditions under which it proves serious are when the 
intertrigo attacks children laboring under chronic entero-colitis, or those 
affected with severe thrush connected with gastro-intestinal inflammation, 
when it cannot fail to increase the sufferings and danger of the patient ; or, 
when it implicates, as we have seen it do in two instances, extensive por- 
tions of the cutaneous surface, involving the folds of the neck, armpits, 
groins, and genital organs, and this, too, without any other signs of dis- 
order of the digestive apparatus than those showing functional derange- 
ment. In one of these cases the extent and depth of the ulcerations were 
so great, and the resulting suffering and constitutional distress so severe, as 
to have very nearly destroyed the life of the infant, who was but two 
months old at the time of the attack. 

Erythema nodosum would almost certainly excite some uneasiness in the 
mind of a practitioner unacquainted with its real nature and probable 
course, and not only so, but it would prove tedious and difficult of cure, 
unless treated in the proper way. When managed correctly, however, it 
almost always gets well without any difficulty. 

Treatment. — Erythema fugax requires no special treatment. The dis- 
order which has occasioned it is the point to which our attention must be 
turned, and not the eruption, which is a mere consequence. 

Ordinary, mild cases of intertrigo require no other measures than at- 
tention to strict cleanliness. The irritated parts must be carefully washed 
two or three times a day, and if the nates, genital parts, and thighs are 
concerned, the washing must be repeated after each evacuation of urine or 
stool. After this the parts should be dusted with fine starch, with the pow- 
der of chalk or lycopodiura, or with calomel, which, in our hands, has 
answered best of all, or else be well anointed with some mild ointment, 
the best of which is, in our opinion, Goulard's cerate. The washing ought 
to be performed with a fine soft sponge and warm water. The sponge is far 
better than the cloth generally employed, because, with the former, the 
cleansing can be effected by pressure, whilst with the latter it is necessary 



TREATMENT. 887 

to use a kiud of wiping or rubbiug process, which caunot fail to irritate 
the inflamed and tender surfaces. 

When the surfaces have become excoriated or ulcerated, attention to 
cleanliness is as important as ever. The application of the drying pow- 
ders generally employed by the public becomes, under these circumstances, 
insufficient, and often rather injurious, except, indeed, in cases in which 
the excoriation is very slight ; here the lycopodium powder, or very fine 
starch or magnesia will sometimes answer a good purpose. When the ex- 
coriation is severe, and when ulceration is present, we have never obtained 
any good effects from powdering ; on the contrary, it has often proved in- 
jurious, and is at least troublesome and annoying from the incrusting of 
the powder about the ulcer. We prefer, therefore, very greatly, when ul- 
ceration is present, to dress the part with simple cerate, Goulard's cerate, 
Turner's cerate, or with ointment of oxide of zinc. The ointment should 
be applied on a fine rag greased on one side, the rag being doubled and 
interposed in such a way between the opposite surfaces of inflammation 
as to be accurately applied to the whole extent of the disease, and thus 
prevent all friction or even contact of the opposite sides. These com- 
presses ought to be changed three or four times a day, and all the dis- 
charges gently but carefully washed off by pressure with the sponge 
between each change of dressing. 

Whilst this topical treatment Is being carried out, constant attention 
must be paid to the state of the digestive function. It is scarcely neces- 
sary to apply this remark to cases occurring in the course of thrush or 
entero-colitis ; but there is another class of cases that we have met with, 
in which, though the intertrigo is severe and obstinate, lasting as much as 
two, three, or four weeks, the signs of gastrointestinal disorder are so slight 
as to pass unnoticed unless carefully inquired into. Thus they may consist 
merely in the fact that a child has a few more stools per day than usual, or 
that the stools are more liquid than they should be, or that they exhibit 
marks of derangement of the digestive process by the appearance in them 
of imperfectly digested curd of milk, or by their green color and sour smell. 
Whatever be the character of the derangement of this function, as shown 
by the general appearance of the child, its appetite, degree of thirst, or the 
appearances presente<^l by the stfK)ls, we should always endeavor to rectify 
the disorder, and if the attempt prove successful, we shall often see th(; in- 
tertrigo vanish at once, while before it had resisted all tho mcins employed 
for its cure. 

Er}'thema nodosum occurs generally, as already stat<_<i, in feeble chil- 
dren, and is usually accompanied with constipation or unhealthy stools, 
and slight febrile reaction. The proper treatment is a laxative at the 
beginning of the attack, and again in the course of the disorder, if nec- 
ess&ry ; rest in bed, or on a sofa, which is very important ; and, after the 
operation of the laxative, the administration of tonics, and the use of a 
light but strengthening diet. The best t^mic, a.s a general rule, is quinia. 
If this is not liked, or if there be anything in the case to contraindicate 
its employment, we may substitute the compound tincture of bark, in 
the dose of fifteen or twenty drops, three times a day. If the child is pale 



888 ERYSIPELAS. 

and anaemic, iron is the proper remedy. It should be given in connection 
with the tincture of bark, or with small doses of brandy, when the appe- 
tite is poor, and the strength and spirits of the child much below their 
natural level. 

Topical remedies are not necessary as a general rule. When, however, 
the local symptoms are severe, or there is much heat or pain in the tumors, 
they should be kept covered with compresses moistened with some kind of 
mucilage, or with lead-water and laudanum. 



ARTICLE II. 



ERYSIPELAS. 



Definition; Forms; Frequency. — Erysipelas is a specific, acute, 
febrile, non-contagious exanthem, characterized by a deep red rash, at- 
tended with heat and swelling of the skin, sometimes with inflammation 
of the subjacent cellular tissue, and terminating generally in resolution, 
but sometimes in suppuration or gangrene. The disease is very variable 
as to its extent, and has the peculiarity of spreading from place to place, 
the part first attacked recovering, whilst the neighboring surface is be- 
coming affected. 

The disease, as it occurs in children over six months of age, presents the 
same characters as in adults, and requires therefore no particular attention 
in this work. In younger children on the contrary, and especially in the 
new-born infant, it is different in several particulars from that of older 
children or adults, and this we shall attempt to describe. The form 
which occurs in new-born infants, has been technically named erysipelas 
neonatorum. 

Erysipelas is a rare disease in private practice, particularly amongst 
families in easy circumstances. In lying-in and foundling hospitals, on 
the contrary, it is of frequent occurrence, and it is not uncommon in hos- 
pitals for children and in the children of the poor. We have ourselves 
met with but four cases of erysipelas in children under six months of age, 
whilst we have met with seven in older children. 

Causes. — The erysipelas of young children almost always starts from 
some previously existing cutaneous inflammation, the most frequent seats 
of which are the umbilicus during the process of separation of the cord, 
the irritated folds of the skin existing in erythema intertrigo, the inflam- 
mation accompanying the vaccine disease, and that which exists in the 
eczematous and impetiginous eruptions of the scalp, ears, and face. In a 
large majority of the cases observed in new-born children, the disease 
begins upon the abdomen, and generally at the umbilicus. In those which 
occur in children at the breast, it may show itself at any of the points 
above mentioned. 



I 



SYMPTOMS. 889 

The disease occasionally follows vaccination. AVo have ourselves met 
with three instances, in two of which the erysipehis broke out about the 
eighth clay ; and in the third on the tenth day. In none of these cases 
could there be any doubt as to the purity of the vaccine virus used. In 
two, the disease extended over the greater part of the cutaneous surface, 
lasting three weeks, but terminating favorably in both cases. In the tliird 
case, it extended over the whole of the vaccinated arm, then attacked the 
upper part of the trunk, the face, and the riirht arm, and terminated faU\lly 
in the second week. 

But, though erysi[>elas commonly starts tVom, and may at first view 
seem to be produced by these ditlerent local irritations, it is impossible to 
suppose that they can be anything more than the exciting agencies or 
causes, which bring into action a disease of which the seeds already exist 
in the economy. We must, therefore, in order to untlerstand the real 
mode of causation of erysipelas, seek for the conditions that give rise to 
this predisposition to the malady, without which the above-mentioned ex- 
citing causes would rest without effect. These conditions are either a gen- 
eral epidemic constitution of the air, affecting certain district.^ of country, 
and acting more or less upon all classes of the community, but with especial 
force upon the destitute and miserable ; or else a local epidemic constitution, 
such as that often occasioned by the unfavorable hygienic conditions of 
hospitals, and particularly of lying-in and foundling hospitals, or that not 
unfrequently determined by the same causes in the crowded and miserable 
habitations of the poorer classes of the inhabitants of large towns and 
cities. 

Symptoms. — Inraniile erysipelas is not generally preceded by any con- 
stitutional symptoms. The appearance of the eruption is usually the first 
sign of the disease. So soon, however, as the eruption appears, or very 
soon after, the child is attacked with fever, marked by frequent pulse, 
heat and dryness of the skin, restlessness and insomnia, and thirst. In the 
form of the disease which occurs in very young infantsi and in hospitals, or 
amongst the lower classes of the population, the eruption almost always 
begins upon the abdomen, and very generally at the umbilicus, whence it 
extends to the rest of the trunk, to the genital parts, and sometimes to the 
inferior extremities. Kven under the circumstances just mentioned, how- 
ever, the eruption sometimes commences upon the face or upon the limbs. 
In children over two weeks of age, and in those observed in private prac- 
tice, the di.sease may begin upon any part of the surface. It very often 
commences in the neighborhood of a vaccine pock, in a patch of erythema 
intertrigo, whether this l)e seated on the neck or about the jwlvis, or it may 
appear first upon the face, or U|)on one of the extremities, without any ap- 
parent exciting cause, and extend thence with greater or less rapidity to 
other parts of the body. 

The form of the disease which occurs in very young infants, and which 
is by far more frequent in lying-in and foundling hospitals than under any 
other circumstances, begins almost always, at least when of a severe type, 
OD the aMomen. It attacks hearty as well as more delicate children, and 
U generally ver}' rapid in its progress. The erysipelatous surface is at 



890 ERYSIPELAS. 

first of a bright-red and shiuing appearance, but soon assumes a purplish 
hue, and as this occurs, becomes exceedingly hard to the touch, and some- 
what, though not very much swelled. As the case goes on, unless resolu- 
tion, which is a rare event, should take place, or death occur at an early 
period, the purple color deepens into livid, vesications occur, the cellular 
tissue is destroyed, and in many instances extensive gangrene takes place, 
so that the scrotum has been seen to " become black and slough away, 
leaving the testicles bare, and hanging loose by the cords." (Maunsell and 
Evanson.) In a case that occurred to one of ourselves in private practice, 
the disease began on the ninth day at the umbilicus, and involved the soft 
tissues of the anterior wall of the thorax and abdomen. The skin sloughed 
in several places, exposing the muscles ; and at one point, just below the 
epigastrium, perforation of the abdominal wall occurred. Death occurred 
on the fifteenth day of the disease. In this form of infantile erysipelas, 
examination after death almost always discloses severe and extensive peri- 
toneal inflammation, a condition which cannot fail, of course, to add greatly 
to the danger of the disease. 

But infantile erysipelas does not always exhibit these violent characters, 
though whenever it occurs in infants under a year old it must be regarded 
as a very dangerous affection. When it attacks children over two weeks 
or a month old, it usually starts, as has been stated, from the neighbor- 
hood of a vaccine pock, from the inflamed surfaces of intertrigo or those 
of eczeraatous or impetiginous eruptions, or it begins without evident cause, 
as in adults, on the face, or on some part of the extremities. It appears 
first in the shape of a bright-red inflammation of the skin. After a short 
time the erysipelatous surface becomes tense, shining, very hot, slightly 
swelled, and painful to the touch. Pressure causes the color to disappear, 
but this rapidly returns when the pressure is removed. Coiucidently with 
the appearance of the cutaneous redness the child is seized with fever, rest- 
lessness, and severe thirst. From the spot first attacked the disease ex- 
tends rapidly to the neighboring surfaces, from the neck and arms to the 
head and trunk, and from the groins or genital parts to the rest of the 
trunk and to the inferior extremities. When it begins upon the face, it 
extends to the scalp, and may thence travel over the whole surface, or it 
may remain limited, as it often does in adults, to the head alone. In one 
case that we saw, in an infant three weeks old, in which it began upon the 
face, it extended gradually over the whole cutaneous surface, and yet the 
child recovered. In another, two months old, it began upon the bridge of 
the nose, and from thence extended over the whole head, but did not reach 
the trunk or limbs. In a third case, a vaccinated arm was attacked with 
erysipelas on the eighth day of the vaccination. The disease extended 
down to the fingers, and upwards to the shoulder. From the shoulder it 
spread gradually over the whole trunk, and down the whole length of both 
lower extremities. As it was subsiding on the feet, it appeared on the arm 
opposite the one first attacked, and then attacked the corresponding side 
of the head, where it ceased. The child finally recovered after an illness 
of three weeks. 

As the peculiar inflammation spreads to the neighboring surfaces, the 



DIAGNOSIS. 891 

parts first attacked lose their red color and swelling, and undergo a pro- 
cess of desquamation. In some instances, the intlamination has caused 
suppuration of the subcutaneous cellular tissue, so that even when the 
greater part of the surface first attacked has ceased to present the peculiar 
characters of the erysipelatous inflammation, there remain behind abscesses 
of greater or less extent. Thus, in one of the cases that came under our 
own notice, when the erysi}>elas had left the head and thorax, and was con- 
fined to the pelvis and inferior extremities, there were two abscesses on 
the scalp, and one over the right pectoral muscle, whilst all the skin be- 
tween the abscesses had regained its natural appearance, with the excep- 
tion of the desquamative process, which was going on as usual. In another, 
but rarer set of cases, the inflammation sometimes returns to the parts over 
which it has already passed. 

The swelling which accompanies this disease is usually of an (edematous 
nature, — the axlema being most marked in the hands and feet, and upon 
the face, whilst upon the trunk it is much less considerable. 

The general symptoms consist at first, as already stated, of those indi- 
cating a strong febrile reaction. If the case goes on favorably these symp- 
toms continue until the disorder terminates. But when the disease is se- 
vere, and especially when it ends in vesication, in extensive destruction of 
the cellular tissue, or in gangrene, the general symptoms are much more 
violent, marking thereby the gravity of the attack. The face and lips 
become pale, and the tongue and mouth dry. The child is in a state of 
constant agitation at first, and expresses its uneasiness and suflering by 
incessant moaning or crying, but, after a time, it becomes heavy and drowsy 
from exhaustion. The pulse is very frequent and feeble; diarrluea and 
vomiting make their appearance, and the child dies at last in a state of 
profound debility ; or convulsions occur towards the last, and terminate 
the case, as they so often do in the diseases of infancy and childhood. 

The duration of erysipelas in children is extremely uncertain, and de- 
pends very much upon its form. In that which occurs in the new-born 
child, or within one or two weeks after birth, it sometimes proves fatal 
within seven days according to Canstatt (Handbuch der Med. Klhiik, 2d 
ed., vol. ii, p. 26'4). M. Bouchut {Mai. des Enf. Nonv.-N(% p. 532) gives 
as an approximation to the ordinary duration of infantile erysipelas, be- 
tween four and five weeks, and states that this is also the result arrived at 
by M. Trousseau. In one of the ca^^es alluded to by us, in which the dis- 
ease extended over the whole cutaneous surface, the duration was four, 
while in another it was three weeks ; in the one in which the eruption was 
limited to the head, the duration was a week. In the seven remaining 
cases, the disease was limited to the nose and eyelids, or the face and scalp, 
and lasted from three to ten days. 

DiAGNOHi.**.— The diagnosis is very easy. The peculiar shade of the 
red color, the presence of decided though mmlerate tumefaction of the 
aflfected part, the severity of the general symptoms, and the character- 
istic erratic mode of extension from surface to surface, all assist to render 
the diagnosis very clear to those who have a proper amount of medical 
knowledge. 



892 ERYSIPELAS. 

Prognosis. — Erysipelas is always a dangerous disease in young chil- 
dren. The precise degree of danger in individual cases will depend chiefly 
on two circumstances : first, the age of the subject ; and second, the hygi- 
enic conditions under which the disease occurs. It is exceedingly danger- 
ous in new-born infants, so much so indeed that M. Bouchut declares that 
they all die {loe. cit., p. 532). This is in all probability almost strictly 
true of the cases which occur in infants only a few days old, particularly 
when they take place in lying-in hospitals, or even in private practice, 
during the prevalence of an epidemic of puerperal fever. The disease is 
always very dangerous in hospitals, even in infants over two weeks old. 
Yet it would appear not to be so grave as represented by M. Bouchut, 
who thinks that very few indeed have been cured even at that age ; for, 
of thirty cases in infants between one day and a year old observed by Bil- 
lard at the Foundling's Hospital of Paris, sixteen, or only one more than 
half, proved fatal. Schwebel reports 54 deaths in S6 cases (Meissner, 
Kinderkrankheiten, 3d ed., vol. i, p. 372). 

In private practice, erysipelas, as it occurs in children between two 
weeks and a few years old, is a dangerous malady, but yet is far from 
being so in the same degree as in the new-born infant, and in hospitals. 
We have already stated that we have seen four cases in young infants ; 
one nine days old, in whom the disease proved fatal in fifteen days ; one 
three weeks old, in whom the disease lasted four weeks, and travelled 
over the whole cutaneous surface ; another ten weeks old, in whom also 
it travelled over the greater part of the cutaneous surface ; and a fourth 
two months old, in whom it remained limited to the head. These last 
three recovered. Again, we have seen seven cases of erysipelas of the 
face or head in children between seven months and twelve years old, and 
these also ended favorably. It must be recollected, however, to account 
for these recoveries, that they all occurred in hearty children, and under 
the most favorable hygienic conditions met with in private practice. To 
conclude, MM. Rilliet and Barthez report nine cases of erysipelas of the 
face in children, all of whom, with three exceptions, were over five years 
of age. Five of the nine cases were idiopathic; in four the disease com- 
plicated other aflTections. All of the spontaneous and one of the compli- 
cated cases recovered. The two others, both of which occurred in subjects 
laboring under measles attended with pneumonia, proved fatal. 

Treatment. — The treatment of erysipelas in new-born infants, espe- 
cially when the subjects of the disease are the inmates of a hospital, and 
when it occurs coincidently with a puerperal fever epidemic, is, as may 
be learned from the almost certain fatality of the disorder, exceedingly 
hopeless. M. Trousseau (Barrier, Traite Prat des Mai. de I'Enfance, t. ii, 
p. 560) has made trial unsuccessfully of emollients in every form, of fomen- 
tations, lotions, baths, and of ointments containing sulphate of iron. " I 
have tried," he says, "surrounding the whole body and limbs with blisters 
in the form of strips ; the erysipelas has passed over the obstacle. I have 
applied without success blisters upon the surfaces already invaded by the 
inflammation. I have obtained no advantage from mercurial ointment or 
from baths containing corrosive sublimate." He even tried the applica- 



TREATMENT. 893 

tion of the actual cautery in points where the disease was beginning, but 
without efiect. So, too, with methodical compression. 

Underwood says that "upon the complaint being first noticed in the 
British Lying-in Hospital, various means were made use of without suc- 
cess ; the progress of the inflammation has seemed, indeed, to be checked 
for awhile by saturnine fomentations and poultices, applied on the very 
first appearance of the inflammation ; but it soon spread, and a gan«rreno 
presently came on ; or where matter has been formed, the tender infant 
has sunk under the discharge." He adds that he then proposed bark, to 
which sometimes a little confectio aromatica was added, and that from that 
period several cases recovered. After this, linen compresses, wrung out 
of camphorated spirit, were applied in the place of the saturnine solution, 
and proved successful in several instances in checking the inflammation. 
*' Nevertheless, the greater number of infants attacked with this disorder 
sink under its violence, and many of them in a very few days." (^Treat. on 
the Dis. of Children, Am. ed., by Dr. Bell, from the 9th Eng. ed., p. 103.) 
In a note to the above. Dr. M. Hall states that fomentations of extract of 
poppies diffiised in warm water, and poultices consisting of the same fluid 
and crumbs of bread, proved beneficial in many instances. Dewees rec- 
ommends the application of a blister, when the erysipelas is so situated as 
to allow the whole surface of inflammation and a portion of the neigh- 
boring healthy surface to be covered by the plaster. When this cannot 
be done, he prefers the use of the strong mercurial ointment, which must 
be applied over the whole of the eruption, and partly upon the healthy 
skin, and renewed as often as the part becomes dry. 

It is very difficult amidst the variety of advice given by different writers, 
and especially when we reflect upon the great mortality of the disease under 
ever}' kind of treatment, to determine which to select. For our own part, 
we should prefer the use of cooling emollient applications during the first 
part of the attack, whilst the skin is of a bright red color, hot, and shin- 
ing. When the circulation becomes languid, and the color of the erup- 
tion is disposed to deepen from red to purple, we should suspend the use 
of the emollient applications, and employ instead the lotion of camphor- 
ated spirit recommended by Underwood ; the camphorated tincture of 
soap, which we have known to be of great service in the erysipelatous in- 
flammations occurring in patients of broken-down constitution, and which 
is to be applied three or four times a day by means of a soft sponge ; or 
lastly, we would make trial of Kentish's ointment, a remedy found of 
great service by the late Dr. Charles D. Meigs, in the erysipelas of chil- 
dren (Xorth Ajnf>r. Mrd. and Surg. Joiirn., vol. vi, p. 77). Tliis ointment 
he prepared by rendering ba.«ilicon ointment soft (not fluid) with spirit of 
turpentine. It is rubbed upon the inflamed part with the fingers, the 
anointing being " repeated often enough to keep the part always very 
thinly covered." The internal treatment should consist in attention to 
the .state of the bowels, which arc to be kept soluble by the mildest lax- 
atives, without being purged, and in a resort to toDJc and stimulating 
remf-di^s upon the very first approach of symptoms indicating exhaustion. 
The be.-'t remedies of thi.s cla.ss are proper diet, wine whey, small quanti- 



894 ERYSIPELAS. 

ties of brandy, and bark in connection with minute doses of carbonate of 
ammonia. 

In addition to these, the tincture of the chloride of iron, whose remark- 
able and almost specific influence upon the course of erysipelas in more 
advanced life is so well established, should be given in large doses, pro- 
portioned to the tender age of the patient. Thus we may give two or 
three drops every three hours to an infant of a month old, as in the follow- 
ing formula : 

R.— Tr. Ferri Chloridi, f^ss. 

Acid. Acetic Dil., f ;5ss. 

Liq, Ammonise Acetat., ..'... f.^j. 

Syr. Simp , f^^ss. 

Aquse, ad f^iij.— M. 

S. — A teaspoonful every three hours. 

When the inflammation has gone on to the production of subcutaneous 
suppuration, it becomes still more important to sustain the forces of the 
constitution, by giving the infant a healthy and abundant breast of milk, 
and by the internal use of brandy in small quantities, of bark, or better 
still, of quinia in combination with small doses of carbonate of ammonia. 
At the same time the suppurating surfaces must be well fomented, and 
dressed with warm poultices, and, when necessary, laid open by careful 
incisions, observing the precaution to cause as small a loss of blood as pos- 
sible. If the case occur in a hospital, or in a child placed in unfavorable 
hygienic conditions, let the following statement of M. Barrier (loc. cit, t. 
iii, p. 562) be borne in mind : " However much the life of an infant be 
threatened by erysipelas, if we can but persuade a wet-nurse to take charge 
of it, the pure air of the country is often seen to replace most advantage- 
ously all other therapeutical resources." 

As the preceding remarks have been restricted to the form of the dis- 
ease which occurs in infants under two weeks of age, we have now to make 
some observations on the cases which occur in older children. 

The disease is still, even at this latter age, a very dangerous one, though 
much less so, certainly, than in the new-born child. We have been de- 
terred from the use of depletion in any form by two reasons, — the fear of 
exhaustion, which is so apt to occur in the disease, and the apprehension 
lest the leech-bites or cup-marks, in the case of local depletion, might 
prove new foci of the erysipelatous inflammation. The only internal reme- 
dies necessary in the beginning, are such laxatives as may be required to 
keep the bowels soluble when they are bound, such as shall correct acidity 
or diarrhoea when either is present, and those which promote an open state 
of the skin, and a free discharge of the urinary secretion. For the latter 
purpose we know none better than the solution of the acetate of ammonia, 
and the sweet spirit of nitre, about twenty or thirty drops of the former, 
with five of the latter, in sweetened water, to be repeated every two or 
three hours. The tincture of the chloride of iron should also be given, in 
the combination before recommended, in large doses, as three to six drops. 



TREATMENT. 895 

every three hours, at the age of one or two years. Should the attack be 
attended by any symptoms of prostration, or at a later period of the dis- 
ease, when the child begins to emaciate and grow feeble, its strength must 
be carefully supported by the use of proper diet, and of stimulants and 
tonics. The only proper diet for nursing children is, of course, breast- 
milk : for those who have been weaned, the diet should consist of prepara- 
tions of milk, light animal broths, or beef teii. The best stimulants are 
five or ten drops of brandy, five drops of aromatic spirit of hartshorn, or 
a quarter or sixth of a grain of carbonate of ammonia, in weak syrup of 
ginger, to be administered four or five times a day, or more frequently, 
when the forces of the child are greatly prostrated. The proj^er tonic is 
from a quarter to half a grain of extract of bark, or half a grain of quinia, 
in some suitable vehicle, every three or four hours. 

The best local treatment is, in our opinion, cooling or tepid emollient 
applications, as slippery elm bark, marsh-mallow, or flaxseed tea, during 
the first few days, whilst the reaction is marked, and the calorification of 
the body high. Somewhat later, when the strength begins to be reduced, 
and the color of the eruption to deepen, we should make use either of 
mercurial ointment, which is highly recommended by some, or of the 
Kentish's ointment, or camphorated tincture of soap, to which attention 
has already been called. We would here propose the trial of an ointment 
which we have found not only soothing and comforting to the child, but 
also of manifest curative efficacy in the violent cutaneous inflammation of 
scarlatina. It consists of one ounce of fresh cold cream, rubbed up with a 
drachm of glycerin. It should be smeared over the inflamed surface sev- 
eral times a day, and need not interfere with the use of emollient applica- 
tions. In scarlatina it has been most useful in reducing the burning heat 
of the eruption, and in softening the hai-sh and distended skin, and by 
these efl^ects has aided greatly in moderating the severity of the general, 
and especially of the nervous symptoms. 

In children over two or three years of age, erysipelas must be treated 
on the same principles as in adults, by light but nourishing diet, and rest 
io bed, by the internal use of laxatives occasionally, of full doses of the 
tincture of chloride of iron, and of febrifuges, and by the external appli- 
cation of emollient infusions, so long as the symptoms remain acute and 
the strength unreduced. But when, after a time, the fever begins to sub- 
side, or the child begins to show signs of debility and a tendency towards 
the typhoid condition, we must endeavor to maintain the life-actions in a 
proper degree of energy by a more nourishing and abundant diet, by the 
prudent administration of bark or of quinia, and even by the use of 
brandy and ammonia, should the strength of the patient be disposed to 
give wav suddenly or rapidly. Under these circumstance^, moreover, the 
best local application will be either the Kentish's ointment, or the cam- 
phorated tincture of soap. 



896 ROSEOLA. 

ARTICLE III. 

ROSEOLA. 

Definition; Synonyms; Frequency; Forms. — Roseola is a Don-con- 
tagious, fugacious exanthem, characterized by rose-colored patches, of 
irregular size and shape, which are unaccompanied by elevations or 
papules, and the appearance of which is preceded and accompanied by 
febrile symptoms. 

It is often called in this country scarlet rash, and under that title sup- 
posed to constitute a very mild form of scarlatina. It is sometimes called 
also French measles, and rubeola sine catarrho. By some writers, as 
Duhring, roseola is included under the general term of Erythema. 

Roseola is of rather freqiieiit occurrence amongst children, though more 
rare than either measles or scarlet fever. 

There are three forms of the disease met with in children, roseola sestiva, 
roseola autumnalis, and roseola annulata. As the two former, however, 
present no differences of any importance, we shall describe them under 
one head, whilst the latter, quite unlike the other two, requires that we 
should describe it apart. 

Causes. — Roseola may occur at all ages of infancy and childhood, and 
at any season, but is most common in summer and autumn. It has been 
known to prevail as an epidemic, but has never been thought contagious. 
It may attack the same individual on several different occasions, one 
attack not preserving from repetitions. The variolous eruptions are some- 
times preceded by roseola, and in some children it makes its appearance 
on the ninth or tenth day of the vaccine disease. Of the various causes 
that we have known to produce it, the most frequent is certainly derange- 
ment of the digestive function during the first dentition. It is said also 
to be occasioned by sudden changes of temperature, by violent exercise, 
and by the use of cold drinks while the body is heated and moist with 
perspiration ; causes which strongly indicate that the nervous system is 
closely connected with its production. 

Symptoms. — Young children who have been suffering for a few days 
with disorder of the digestive function, often exhibit a slight roseolous 
eruption, lasting twenty-four or thirty-six hours, and then disappearing. 
The eruption in this mild form of the disease appears suddenly, often in 
the course of a single night, covering the trunk or even the whole surface 
with numerous patches, nearly circular in shape, or in irregular, broad, 
and waving lines, situated close together, and yet distinct, and of a light 
rose color. In another, and rather more violent form, occurring especially 
during dentition, the eruption appears after vomiting, fever, diarrhoea, and 
slight nervous symptoms, or possibly after slight convulsions, with the 
characters above mentioned, except that the rash is deeper in color, greater 
in extent, and that it lasts generally a longer time — two, three, or four 
days. Again, in a yet more marked form, the roseola sestiva and autum- 



SYMPTOMS — DIAGNOSIS. 897 

nalis, the disease is preceded by certain symptoms which it is important to 
note. It begins with more or less chilliness, alternating with heat, with 
loss of strength and spirits, with headache, restlessness, sometimes mild 
delirium, and even, it is said, though we have never seen them, with slight 
convulsive phenomena. At the same time there is some iebnic reaction, 
marked by aecelerateii pulse, heat and dryness of the skin, thirst and loss 
of ap|)etite ; the digestive function is shown to be deranged by the presence 
either of constipation or diarrhoea. After these symptoms have continued 
tbr two, three, four, or even six or seven days, the eruption appears first 
upon the face and neck, whence it extends in twenty-four or forty-eight 
hours to the rest of the body. The rash resembles very closely, in some cases 
exactly, that of measles. It is in the form of irregularly circular and rather 
large patches, at first of a red, but soon changing to a deep rose color, 
and separated from each other by portions of healthy skin. The eruption 
is sometimes accompanied by itching, and sometimes by stinging pain, 
and the febrile symptoms generally continue, though moderated in degree, 
at\er the appearance of the rash ; while in other instances the fever disap- 
|)ears entirely from that moment. The rash last^ between one and two or 
three days, as a general rule, and fades away gradually until it has en- 
tirely disjippeared. In some cases it comes and goes alternately for a week 
after its first appearance. 

Roseola Axnulata is a curious and interesting form of the disorder, 
from the singular and beautiful appearance of the bright rose-colored 
rings which constitute the eruption. We have seen but a few examples of 
this variety, while we have met with a large number of cases of the other 
forms. It must, however, be of rare occurrence, since MM. Guersant and 
Blache state that they have never chanced to meet with it, though they 
have seen a large number of roseolous eruptions {Diet, de Med., t. xxvii, 
p. ij'li)). 

This variety of roseola appears in the form of rosy rings, or circles, 
whose centres retain the natural color of the skin. The favorite seats of 
the eruption are the abdomen, loins, buttocks, or thighs, or it may cover 
the greater part of the body. In one case that we saw, the eruption cov- 
ered the face, neck, and trunk. In another it was seated upon the face, 
trunk, and upper extremities. The rings are at first not more than one 
or two lines in diameter, but they enlarge gradually until their centres 
measure as much as half an inch in diameter. In some irjstanres two 
or three rings surround one another,'lhe skin in the intervals between 
them still retaining, however, its natural appearance. The disease is, 
when accompanied by symptom** of reaction, u.«<ually of short duration. 
The cases which occurred to ourselves lasted only three days, ancl were 
accompanied by decide<l febrile symptomj*, together with signs of diges- 
tive derangement. It sometimes a^v^ume-* a chronic form, the eruption 
fading in color in the moroing, and increasing again and causing heat of 
skin, in the evening. 

DiAfJXOsLs. — Roeeola sestiva might be readily mistaken by a careless 
observer for mea-sles or scarlatina, and especially for the former. We have 
no doubt whatever that cases of roseola are often regarded, under the title 

67 



81'8 ROSEOLA. 

of scarlet rash, as examples of a very mild form of scarlatina, a misap- 
preheDsion which will explain some at least of the supposed instances of 
second attacks of scarlet fever in the same individual. This is a mistake, 
however, that ought not to occur, and need not, if the following characters 
of the two diseases are properly understood. The rash in scarlatina is, in 
the first place, of a much brighter tint, and it is more persistent and more 
uniformly spread over the surface than in roseola. When we come to ana- 
lyze the characters of the two eruptions, there are other distinctions be- 
tween them which assist greatly in making the diagnosis. In scarlatina, 
the eruption is composed of very large patches, or it is absolutely uniform, 
and evenly distributed over large surfaces, as over the whole trunk, or over 
the flexor or extensor aspects of the limbs. It is seen to be composed, too, 
when minutely examined, of an aggregation of very minute red points, 
which are dotted so closely together as to present the appearance of a 
general scarlet blush. In roseola, on the contrary, the rash is composed of 
irregularly circular, crescentic, or waving patches, with portions of skin 
between of a natural or nearly natural color. The patches, moreover, are 
of a different tint from that of scarlatina, being of a deep rose, instead of 
a bright red or scarlet color, and they cannot, upon close examination, be 
resolved into the minute dotted points which make up the scarlatinous 
eruption. When we add to these circumstances the facts, that in roseola 
there is no faucial inflammation, that the pulse has not the great frequency 
almost invariably present even in very slight cases of scarlet fever, that 
all the general symptoms are much less strongly marked, that no desquama- 
tion takes place in roseola, and that the duration of the attack is much 
shorter, we think we have points of difference between the two, quite nu- 
merous and marked enough, to render the differential diagnosis easy to a 
careful observer. 

It has always seemed to us impossible to distinguish with certainty be- 
tween roseola and measles by the eruption alone, and we find that MM. 
Rilliet and Barthez are also of this opinion {Mai. des Enfants, t. i, p. 732). 
We are told by writers that in roseola the patches composing the eruption 
are more distinct, larger, paler, and more irregular in shape than in measles, 
and that they are separated by intervals of healthy skin ; but we are quite 
satisfied that, in some cases witnessed by ourselves, these differences were 
not suflicient to distinguish them. The diagnosis is to be made by atten- 
tion to the following points : by the absence of catarrhal symptoms in 
roseola, by the slighter severity of *all the general symptoms, and by the 
much shorter duration and greater irregularity of the initial phenomena, 
which latter seldom last in roseola more than one or two days, and consist 
of symptoms of gastro-intestinal derangement, whilst in measles they last 
three and almost always four full days, and consist of very strongly marked 
catarrhal or respiratory symptoms, with very slight signs of gastro-intesti- 
nal derangement. 

Koseola annulata is so peculiar and characteristic in all its appearances 
as to prevent its being mistaken for any other disease that we are acquainted 
with. 

Prognosis. — Roseola is probably never dangerous to life. If it ever 






URTICARIA. 899 

seems to be so, it must be in cousequence of its occurring in connection 
with severe internal disease. 

Treatment. — The only treatment neco^jsary in roseola is attention to 
diet ; the correction by that means, or, if necessary, by a mild laxative, 
by some antacid preparation, or by a mercurial dose, ot* the gastric or in- 
testinal disorder; rest in bed, or seclusion in a chamber with a properly 
regulated temperature; and the use of mild diaphoretics and cooling de- 
mulcent drinks. 



ARTICLE IV. 

URTICARIA. 



Definitions; Synonyms; Frequency; Forms. — Urticaria is anon- 
contagious exanthem, characterized by hard elevations upon the skin, of 
uncertain size and shape, and of a reddish or whitish color, or, more fre- 
quently, partly red and partly white; the eruption is generally of short 
duration, is almost always accompanied with intense heat, and violent itch- 
ing and burning, and is preceded by more or less marked signs of gastro- 
intestinal disorder. 

Its most common title is that of netile-rash. The mild, discrete form of 
the disease is generally called hives in the nursery. It is sometimes de- 
scribed under the name of e-^era. It is of very frequent occurrence 
amongst children in a mild shape. We have seldom seen in early life 
the abundant and severe eruption covering the greater part of the sur- 
face, which is met with in adults. 

The most common form of urticaria in adults is well known to be the 
urfirafia f^brili^, which is an acute disease of short duration. Two other 
forms of the disease, the urticaria evanida, and tubcrom, are occa.sionally 
met with in adults, though they are both rare. In children, by far the 
most frequent form of the disease that we have seen is one in which there 
is scarcely any fever whatever, and in which the eruption is moderate ; 
the urticaria febrilis is, however, not at all uncommon in early life, while, 
on the other hand, we have never met with an in.-tance cither (tf urti<:iria 
evanida or tuberosa at the age referretl to. 

Causes. — Children possessing a fine and delicate skin, opocially wlicn 
thev are at the same time endowed with a highly nervous temiHranunt, 
are particularly predisposed to attacks of urticaria. The only other causes 
that we are acquainted! with are the functional disorders of the digestive 
apparatus which occur in the spring and summer seasons, the influence of 
dentition, derangement of the gastric functions from the use of improf)cr 
food, and la.-tly, the ingestion of certain articles of diet, which have l>e*n 
roven by long experience to be apt to occasion attacks of the disease. Of 
the articles last referred to, those which mout frequently produce this effect 



900 URTICARIA. 

are crabs, the eggs of certain kinds of fisb, certain crayfish, and some kinds 
of smoked, dried, or salted fish. 

Some children are exceedingly liable to the appearance upon different 
parts of the body of a fe^y patches of urticaria. Very slight disturbances 
of the gastric functions, a very warm day, or excessive clothing, will occa- 
sion in such subjects an attack of the disorder, whilst in many others 
again, the disease is never seen under any circumstances, or only at rare 
and long intervals. 

Symptoms, — The form of the disorder most commonly met with in chil- 
dren, in which there is neither fever nor other marked signs of disorder of 
the general health, is the disease generally described under the title of 
lichen urticatus, but which ought, it seems to us, to be considered as one of 
the varieties of urticaria, under the name of urticaria papulosa. This 
eruption consists of large inflamed papules, which are irregular in shape, 
being either rounded or oblong, projecting most in the centre, and which ■ 
appear suddenly, without any or with only slight prodromic symptoms. 
The papules are of a bright red color, excepting in their projecting central 
portions, where they are whitish or of a very pale red tint. The eruption 
is accompanied with a smarting and burning pain, and with the most vio- 
lent and annoying itching, which the child endeavors to allay by frequent 
and often rude scratching, in consequence of which the summits of the 
papules are often torn and present litile crusts of dried blood. It is very 
fugacious in its character, appearing suddenly, lasting for a few hours or 
several days, and then disappearing entirely, or recurring again after a 
short time in the same or in new places. It terminates finally, after from 
a few days to several weeks, by resolution or by a slight furfuraceous des- 
quamation. The most common seats of the eruption in children are the 
face, about the buttocks, or upon the thighs, or upper part of the arms. 

This is the form of the disease we have met with in infants, and in chil- 
dren under two and three years of age. It is, as already stated, of very 
slight consequence, being merely annoying and never dangerous. In young 
infants it occasions sometimes much crying and irritability, which can be • 
explained only by the discovery of the eruption. f 

The urticaria febrilis is usually, but not always, preceded for a few 
hours or two or three days, by feverishness, and by more or less marked 
signs of gastric disorder, such as nausea, chilliness, headache, and languor. 
In other instances the fever and the rash occur at the same time. The 
eruption begins with a sense of itching, and with heat and burning of the 
skin, and soon after there appear on the shoulders, loins, inside of the 
arms, and about the thighs and knees, reddish and solid elevations, irreg- 
ular in outline, but generally roundish or oblong. The latter shape is the 
one the elevations most frequently assume, and it is from the resemblance 
which they bear in this form to the marks left by the stripes from a rod or 
whip-lash, that they are often called weals. The elevations project a good 
deal above the surrounding surface, forming knots or ridges ; their size is 
variable ; they have hardened edges ; they are reddish in color, except 
over the central and most projecting part, which is generally, and always 
when the swelling is considerable, whitish in its tint ; and they are sur- 

) 

I 



DIAGNOSIS — PROGNOSIS — TREATMENT. 901 

rouuded by a narrow areola of a bright red or scarlet color. The anunint 
of the eruption is very uncertain, the elevations being sometimes separated 
by considerable intervals of healthy skin, while in severe cases they are 
extremely numerous, and from their confluent character in such attacks, 
give to the part upon which they are seated, a nearly uniform red color, 
and occasion at the same time a very decided puffing aiul swelling of the 
skin. 

The eruption, when at all considerable in degree, is attended with violent 

itching and burning. The former is often so severe and troublesome as to 

'Cca:?ion the most distressing irritation to the patient, precluding all coni- 

>rt or quiet. It is increased by heat, and especially by that of the bed. 

The patches of eruption which appear first do not continue throughout the 

lisease, but, after lasting from a few minutes to a few hours, fade away, 

\nd are replaced by new and successive crops. During the attack, the 

atient is usually more or less feverish, and he suffers from languor, loss 

1* appetite, furred tongue, and the usual signs of gastric derangement. 

Phe symptoms subside gradually, so that, after a period varying from two 

or three days to a week, the disorder ha.s entirely disappeared, leaving 

behind no traces, except, in a few instances, a slight desquamation. 

When this form of urticaria follows the ingestion of certain articles of 
food, the eruption usually appears within a very few hours after the meal, 
being preceded and accompanied by nausea or vomiting, pain and distress 
in the epigastric region, giddiness, headache, and feverishness. 

In cases where the cause persists, and especially among children of the 
poorest classes, who live in squalor, or at least under any unfavorable 
hyirienic conditions, the disease may assume a chronic form. The indi- 
vi'lual weals are more persistent, and the rude scratching and absence of 
cleanliness aggravate the eruption and modify its character. 

DiAGNOJ^is. — There can be no diflBcuIty in recognizing a case of urticaria. 

The peculiar characters of the eruption, and especially the size, shape, and 

olor of the s<jlid elevations of which the patches consist, the violent itch- 

ng and burning which accompany it, and its fugacious character, render 

it unlike any other cutaneous disease, and ought to prevent any mistake 

as to its nature. 

PRCK;Nf><is. — Urticaria is probably never dangerous in children. If it 
' c accompanied by symptoms of a threatening or alarming character, the>*e 
are dependent rather upon the gastric diiiorder, which is the cause of the 
urticaria, than ujxm the latter affection itself. We have never known it 
to he more than troublesome and annoying. 

Treatmknt. — There are but two really important indications for the 
treatment of this disease: to atttend to the state of the digestive func- 
tions, and to allay, by proper means, the distressing irritation occasioned 
by the itching and buniing of the eruption. 

In the mild form of urticaria, called in the nursery, " hives," and in wi- 

«»ntific language, lichen urticatus, the only treatment necessary is careful 

•-gulation of the diet, and the use of means proper to correct any evi- 

ient derangement of the digestive functions. The food should be light 



902 URTICARIA. 

and digestible, but at the same time nourishing. Milk, bread, light meats, 
and the plainest vegetables, form the proper diet for children over three 
years of age. Under that age, milk preparations, bread, and in those 
over a year old, light broths, ought to constitute the diet. In a large 
majority of such cases, no drug whatever ought to be given. The only 
ones likely ever to be required are occasional mild laxatives or gentle 
mercurials, when constipation is present, and some of the antacids, as 
very small quantities of magnesia or carbonate of soda, or lime-water and 
milk, when the stomach is acid. To allay the itching and consequent rest- 
lessness of the child, the patches of eruption should be well and frequently 
dusted with toasted rye or wheat flour, which are often very successful. 
Washing the eruption with salt and water, when the cuticle is not broken, 
is sometimes very soothing, and, when the patches are of small extent, 
this may be done without any impropriety. Dr. Watson speaks well of 
a lotion ("first recommended by Wilkinson"), composed of a drachm of 
carbonate of ammonia, a drachm of acetate of lead, and eight ounces of 
rose-water. 

In the urticaria febrilis the treatment must depend upon the cause of the 
attack. When it follows upon the eating of some unwholesome food, we 
must rid the stomach of the offending substance by an emetic, unless na- 
ture has already caused its rejection by spontaneous vomiting. When 
this end has been gained, it will be proper to give some kind of cathartic 
medicine, and the best is castor oil, as the mildest and most certain, in 
order to insure the discharge of the whole of the aliment which has been 
causing the mischief; or small doses of blue pill; or hydrargyrum cum 
creta, with rhubarb, where there are present any signs of hepatic derange- 
ment. After this the only treatment necessary will be the use of cooling 
and demulcent drinks, containing perhaps a little sweet spirit of nitre ; 
rest in bed, or at least seclusion in the house, for a few days ; and careful 
regulation of the diet. The latter ought to be very light during the con- 
tinuance of the eruption, consisting merely of milk and bread, or of some 
kind of gruel or plain broth ; after the cessation of the disease, it should 
be augmented only with due care and quite gradually. To allay the itch- 
ing and burning of the eruption, and the general distress of the child, the 
best remedy is a warm bath carefully administered. This may be repeated 
in six or eight hours if necessary, and between whiles the surface should 
be dusted with rye or wheat flour, as above recommended. 



ECZEMATOUS AFFECTIONS. 903 



CHAPTER II. 

VESICLES. 

ARTICLE I. 

ECZEMATOUS AFFECTIONS. 

As already stated iu our introductory remarks on skin diseases, the idea 
of eczema is no longer restricted to a disease characterized by the forma- 
tion of vesicles, but embraces all the numerous affections which present 
redness of the skin, frequently punctated; itching, infiltration, and ex- 
udation on the surface, with the formation of crusts. So far, indeed, from 
vesicles being characteristic of it, it may be said, and especially in regard 
to eczema in children, that its rarest form is that which is attended solely 
with their formation. The elementary lesions which may be present at 
the beginning of the attack, are either erythema, papules, vesicles, or pus- 
tules, and the disease is divided accordingly into eczema erythematosum ; 
eczema papulosum, which embraces eczema lichenoides, and eczema pruri- 
gosum ; eczema vesiculosum, the typical eczema of Willan, one of the 
rarest of all its varieties; eczema pustulosum,or impetiginoides, which in- 
cludes impetigo; and eczema squamosum, which is usually of the chronic 
form, and resembles, in many cases, psoriasis. It is indeed called psori- 
asis by Dr. "Wilson, who gives the name "alphos" to that scaly disease, 
which is still, by most authorities, and especially by Hebra, designated as 
psoriasis. 

It not unfrequently happens, also, that the various elementary lesions 
enumerated above may be present at the same time on a patch of eczema- 
tous eruption, so that a ca.se which has begun as eczema erythematosum, 
or vesiculosum, may present the development of papules or pustules, or 
thick scabs, and thus become converted into the pustular or squamous 
form. This tendency for the blending of several elementary lesions in 
the same eruption, and especially for the conversion of the eruption into 
the pustular form, is ver}- markedly seen in cases of eczema of children. 

Eczema is also divided. acr()r<\\n'j to it,- r•()^lr^^•. duration, and staL"'. into 
acute and chronir. 

Eczema shows, moroovfr, an <-])'''iai fcii'l'MH-y in nw-.ick ccrlain parts 
of the surface, and present'^ various p^-culiaritics in the difTcrent loralities; 
in children, it frequently occurs on the scalp and face, though it extend.-* 
over the entire surface of the body far morr* fr< mi, ntlv in th. m tliui in 
adults. 

The special forms of eczema which will be here descnbed, are .simple 



904 ECZEMATOUS AFFECTIONS. 

acute eczema ; eczema of the scalp, and of the face ; eczema pustulosum, or 
impetigo; eczema papillosum ; and chronic eczema, or eczema squamosum. 

Causes. — The causes of these affections are, to say the least, very ob- 
scure in most cases. It is probable that some peculiarities of constitution 
predispose to it, and particularly the lymphatic temperament, or the scrof- 
ulous or tubercular diathesis. Exposure to unhealthy hygienic conditions, 
as want of cleanliness, insufficient or improper food, and crowded or ill- 
ventilated habitations, also render the system more prone to the develop- 
ment of eczema. 

In those who are thus predisposed, any trifling irritation may prove 
sufficient to provoke the eruption. One of the most common and un- 
doubted of these is the influence of the process of teething, and the ma- 
jority of cases of eczema in children occur during either the first or the 
early part of the second dentition. In like manner the application of irri- 
tants of any kind to the skin, or the inflammatory action set up by vaccin- 
ation, may serve as an exciting cause. It is remarkable, also, what slight 
irregularities in diet, or alterations in the quality of the mother's milk, 
will, under such circumstances, induce an attack. Indeed, the use of arti- 
ficial food in infancy, by disordering the digestive function, and impairing 
nutrition, may be regarded as a frequent cause of the disease. 

Symptoms. — We have already alluded to the fact, that in the eczema of 
young children, as indeed is true, to a less degree, of the disease at all 
ages, we constantly meet with the most varied forms of eruption in. the 
same case ; and have the opportunity of watching the development of 
papules, vesicles or pustules, until a case which has begun as one of ery- 
thematous eczema, presents the characters of the papular, vesicular, and 
ultimately of the pustular form. The predominance of one or the other 
of these typical forms of eczema is determined by the temperament and 
general condition of the child, and the grade of inflammatory action 
present. 

Eczema simplex, or vesicnlosum, may occur on any part of the body, but 
in children is most frequent on the face and arms. The eruption appears, 
without any precursory symptoms, as an erythematous patch, which is red 
and itchy, and may present slightly raised pimples, and being rubbed and 
scratched, soon presents the formation of numerous, closely aggregated, 
exceedingly minute vesicles, containing a transparent limpid serum. After 
a short time the contained fluid becomes turbid and then milky, and is 
either absorbed, while the vesicles shrivel up and disappear by a slight 
desquamation, or else the fluid escapes by the rupture of the vesicles, and 
little thin scales follow, which are detached before long from the surface 
beneath. The eruption is attended with more or less itching and smarting, 
but does not generally give rise to constitutional symptoms. The vesicles 
are generally renewed by successive crops; so that, though the case may 
terminate in from two to three weeks, it is apt to continue for two or more 
months. 

Eczema 'papillosum. — In the same way as the above form of eczema is 
characterized by the formation of vesicles, there are other cases where the 
eruption principally consists of papules, associated with erythematous 



1 



ECZEMA CAPITIS. 905 

patches. These papules do not reinaiu dry and without exudation as in 
the typical forms of lichen and strojihulus, hut soon ])resent a slij:;ht clear 
or turbid serous oozing, and thin scaly desquamation of the epithelium. 
At the same time there will usually be found, on other parts of the body, 
patches of more fully developed eczema. The papules in eczeni'x infantile 
may either be firm, small, and conical, as in lichen agrius, or softer, and 
more broad and flat, as in some forms of strophulus. 

Eczema pu.-itulosuvi or Impctigijwidc^^. — Under this head we will describe 
the affection usually styled impetigo, and formerly classed among the pus- 
tular diseases of the skin, but which |x>ssesses peculiarities which have in- 
duced dermatologists to transfer it to the group of eczematous affections. 

It may be described as a form of eczema characterized by the production 
of psydracious sero-pustules, containing a thin purulent fluid, which either 
break and discharge, or dry up and form thin amber-colored or more thick 
yellowish-brown crusts. 

The eruption usually begins as a reddened patch, studded with slightly 
raised pimples. As the inflammation increases, the cuticle is often raised 
into more or less well-defined vesicles, or the surf\ice becomes excoriated, 
and there is a discharge of turbid or whitish-yellow secretion ; the skin 
now becomes infiltrated, and numerous rather small pustules, containing 
a light-colored pus, form on the red swollen surface. Not unfrequently 
there are vesicles on the same patch, surrounding its margin. These pus- 
tules are usually broken by scratching or by friction against the dressings, 
and their contents dry up, forming amber-colored or brownish crusts. 
Frequently, also, blood is mingled with the discharges, and the crusts be- 
come dark-colored, or at times positively black. 

The crusts separate in a few days, the time varying according to their 
firmness and thickness, and leave the surface reddened, but without any 
permauent scar. Frequently, however, the disease passes into a chronic 
form ; the eruption retreats to certain seats, as the scalp, or the flexures 
of the joints, where the skin remains somewhat infiltrated, while the cuticle 
is rough, scaly, and constantly desquamates, either in the form of a fine 
furfuraceous exfoliation, or of scales of considerable size. 

There are in reality but two .specific varieties of this form ol cc/.( tna, 
impetigo figurata and impetigo sparsa, so named from the manner in 
which the pustules forming the eruption are arranged. From the greater 
frequency and .severity of the disease, however, as it appears upon the scalp 
in young children, it has become customary to descrilx; it, when seated 
upon that part, under a different title. 

flrinna rnpHU i« often met with in infants at the breast during the first 
dentition, and at later periods of childhood in those who are scrofulous, or 
who are placed in unfavorable hygienic conditions. It may be confined to 
a small portion of the scalp, or it may cover the head, anfl extend to the 
face and neck ; or again, it may be limited entirely to the latter localitiei*, 
when it constitutea eczema of the face. In both cases, the eruption is 
very apt to run into the pustular form, constituting the disease known as 
impetiL'o capitis. 

When mild in its features, it consists of an eruption of numerous small 



906 ECZEMATOUS AFFECTIONS. 

vesicles or sero-pustules, spread over certain portioDS of the scalp, to which 
it may remain limited ; or it may cover the face at the same time, or it 
may attack alone the forehead, temples, and, perhaps, portions of the 
cheeks. It is attended, under these circumstances, with very slight red- 
ness and heat of the integument. The sero-pustules discharge their fluid 
contents and form thin crusts, which gradually fall off, leaving slightly 
reddened or excoriated surfaces, which soon disappear, or are followed by 
fresh crops of eruption, destined to pass through the same changes as the 
preceding ones. 

In more severe cases the disease may be confined either to the scalp or 
face, or it may, as stated above, exist upon both simultaneously. The 
eruption presents different appearances in these two situations. 

When seated on the scalp, it is often called by the English, milky crust 
or milk-crust, crusta lactea, tinea lactea, and porrigo larvalis ; and by the 
French, croute de lait and gourme. 

On the scalp, as already said, the eruption may be either partial or gen- 
eral. It may consist at first of disseminated minute vesicles, which break, 
and form thin, lamellated crusts, of a yellowish or brownish color ; or of 
pustules, yellowish-white in color, and of small size, seated on an inflamed 
base. The surface affected is at first small, but the eruption gradually ex- 
tends to surrounding parts. It is attended with great heat and itching ; 
and, as the disease advances, the scalp becomes very much inflamed, red, 
tense, swollen, and painful. The eruption is now more completely pustu- 
lar, and as the pustules open or are torn by the uncontrollable scratching, 
they discharge an abundant thin sero-pus, or even a thick and viscid fluid, 
which glues the hairs together, and hardens into uneven brownish-yellow 
crusts. If the scalp is not kept clean by constant washing or by emollient 
applications, the crusts increase rapidly in thickness by successive dis- 
charges of fluid from the pustular surface beneath, until at length the 
whole of the diseased part is covered with thick, heavy, rough, and adher- 
ent crusts, of a brownish or yellowish-white color, or at times of a positive 
black from the admixture of blood which oozes from the inflamed surface, 
torn by the nails of the little sufferer. 

When neglected, the crusts become more and more thick, and from the 
heat of the head and exposure to the air, they undergo partial decomposi- 
tion, and exhale a fetid, sickening odor, of the most disgusting kind. 
Among the children of the poor and destitute, lice often form in abun- 
dance, and add to the repulsive character of the disease. At first, the crusts 
are somewhat soft and moist, from the percolation through them of the 
fluid exuded beneath ; but as they become more abundant and thicker, 
their outer surface becomes dry and sometimes very friable. The secretion 
from the inflamed surfaces often makes its way under the crusted mass 
above, and, flowing down over the forehead and behind the ears, irritates 
the parts that were before healthy, and thus extends the disease. 

"When the crusts are removed by any means, the surface of the eruption 
is found to be red, shining, wet, and discharging an abundant purulent or 
sero-purulent fluid, which escapes from minute excoriated points, dotted 
thickly over the inflamed scalp. The scalp is at the same time tumefied, 



ECZEMA FACIEI. 907 

tender to the touch, and abscesses may form beneath it. The lymi>hatic 
glands, as the occipital, submental, or cervical, are frequently enlarged, 
and at times suppurate. 

"When the disease has lasted a considerable length of time, it tends to 
assume a chronic form. The inflammatory action extends to ihe hair-fol- 
licles, and often occasions partial loss of hair over larger or smaller sur- 
faces. This kind of alopecia is not, however, permanent. The hair-bulbs 
are not destroyed, but merely inflamed, so that the hair grows again after 
the cure of the disease. The tissues of the scalp remain thickened, but 
the amount of the secretion diminishes; and the painful irritation and 
itching are less troublesome. Under these circumstances, the crusts are 
less thick and massive ; they become lighter, thinner, and are more easily 
detached. The epidermis is dry, uneven, and rough, and there is a con- 
tinual desquamation of fine furfuraceous particles, constituting a form of 
pityriasis capitis, or of epithelial scales of various sizes, resembling a case 
of psoriasis. 

On the fac^ {Eczema faciei), the disease usually shows itself fii-st on the 
forehead and cheeks, to which parts it may remain limited, or whence it 
may extend to the lips, chin, ears, and neck. The nose and eyelids are 
seldom attacked, though we have occasionally seen the upper eyelids 
slightly affected. 

The disease begins by the appearance of minute vesicles or sero-pustules 
on a patch of reddened and slightly swollen !«kin ; there is also excessive 
pruritus. When the eruption is scanty, and rather vesicular, and the de- 
gree of inflammation slight, the cuticle breaks, and there is a discharge of 
a thin, turbid, serous fluid, which dries into delicate scales, or thin lamel- 
lated crusts. 

When the accompanying inflammation is more severe, however, the 
eruption is more truly pustular, the pustules being numerous and rather 
large, and the discharge copious, so that when the formation of crusts is 
not interfered with by topical applications, or by the scratching of the 
child, large portions of the affected surface become covered witli thick 
yellowish, brownish, or browoish-red crusts, which present the general ap- 
pearance of a mass of incrustation, broken by cracks and fissures into por- 
tions of ven.' irregular size and shape. 

In the milder ca.se<, when the scales drop off, the skin may api>04ir red- 
dened and moist, or may seem to be covere<l with a very delicate, shining 
epidermis, which is perfectly dry or presents tiny drojw of serum or minute 
cracks. In the more severe cases, if the crusL«< arc detached from any 
cause, the skin beneath appears red, swollen, inflamed, and wetted with a 
more or less abundant sero-punilent fluid, sometimes mixed with blood, 
that oozf- from num« : ill f>oints on the excoriated and inflamed sur- 

face. Th« eruption i 1 with severe itching and «marting, to relieve 

which the child often tears the affected surface with the nails, t^o as fre- 
quently to remove the CrUSt«, "'"t,,! tlu. «i;.i 1.. i..;itl. ;ii.<l r..m-<. tM,.r,. ..r 

less bleeding from the part. 

In this more severe form, whiii tli< i thu k (!;.-( tWurcd 

scab covering the scalp or face like a ; has received the 



908 ECZEMATOUS AFFECTIONS. 

names of porrigo or impetigo larvalis, which are less accurate than eczema 
larvale. It corresponds to the impetigo figurata, as met with in other 
parts of the body. 

When the eruption is more scanty and developed in small groups on 
the scalp alone, the discharge is less copious, and soon concretes into dry, 
friable, brownish crusts of irregular shape, some of which are very ad- 
herent, matting together a larger or smaller number of hairs, while others 
are broken into small and dry fragments, which have been compared to 
particles of mortar dispersed among the hair. Many of the pustules in this 
variety are formed at the base of the hairs, so that these particles of crust, 
being pierced by the hairs, have somewhat the appearance of a string of 
rude beads. This form of the disease has been known as tinea, or impetigo, 
or porrigo granulata ; but for the sake of uniformity, it might be styled 
eczema granulatum. It corresponds to the impetigo sparsa, as met with 
on other parts of the body. 

Eczema larvale, whether confined to the scalp or face or existing on 
both parts at once, causes, when it exists in the acute form, much distress 
and annoyance to the child. The heat and tension of the part, and par- 
ticularly the itching, occasion much restlessness and irritability ; they make 
the child cross and peevish, disturb its sleep, and sometimes cause slight 
febrile attacks, which debilitate and injure the health. Indeed, when the 
disease has lasted a considerable time, it often induces extreme anaemia 
and impairs severely the general nutrition of the child. In other cases, 
however, the general health remains perfect, — all the functions of the body 
going on well, notwithstanding the local distress and irritation. The 
lymphatic glands situated behind and in front of the ear, and those on the 
back and front of the neck often inflame, enlarge, are frequently hard and 
painful to the touch, and in a few instances suppurate, though the latter 
occurrence is not frequent. 

The duration of eczema larvale is very variable in different cases. Mild 
cases, and particularly those in which the eruption is confined to a limited 
extent, often get well, or are readily cured in two or three months. When, 
on the contrary, the disease is severe and extensive, the duration is much 
longer, seldom less, according to our experience, than several months or 
even one or two years. In most cases, however, the intensity of the dis- 
ease varies from time to time, so that at one period it may seem to be sub- 
siding rapidly, or it may even disappear almost, or be very greatly ame- 
liorated, only to break out again with renewed violence under the influence 
of some exciting cause, as the cutting of new teeth, some change in the 
weather or season, or some alteration in the health of the child which can- 
not be explained. This affection is, as already stated, almost entirely con- 
fined to the age of dentition. The disease often begins some months before 
the appearance of the first teeth, and though it generally ceases or is cured 
before the termination of dentition, we have known it to run on unchecked 
three months after the conclusion of that process and then to be removed 
only by medical treatment. 

Eczema granulatum is comparatively a slight disorder, and is usually 
much more under the control of remedies and of much shorter duration. 



ECZEMA CHRONICUM. 909 

There is a local variety of eczema which requires a brief allusion. It is 
kuown as eczema tarsi aiul afiects the edges of the eyolids, especially in 
strumous children, in whom it is often associated with strumous oj^htluUinia. 
It is attended with the formation of pustules at the openings of the liair- 
follicles, itching, thickening of the eyelids from infiltration, the formation 
of crusts, and a tendency to adhesion of the edges of the lids togetlier, espe- 
cially in the morning after they have been in contact during sleep. If not 
cured by appropriate treatment, it frequently leads to distortion of the 
hairs, which assume abnormal directions in their growth, and to inversion 
or eversion of the lids. 

Eczema imjxniginoides also presents itself in other parts of the body 
under the same two forms of impetigo figurata and sparsa which have 
been described as occurring on the head. We have, indeed, more than 
once alluded to the tendency of eczema in children to develop itself in 
different parts of the surface, at times occupying almost the entire cuta- 
Deous surface, and presenting all its varieties at one and the same time. 

Impetigo figurata, when seated on the trunk or limbs, usually presents 
a large eruptive surface. On the arms we have seen it extend from the 
shoulders to the hands, and, as a general rule, it has been most severe on 
the outer portions of the limbs. On the trunk and lower extremities it has 
usually affected surfaces of much less considerable size, and has commonly 
appeared in a patch of an irregularly oval shape, and of four, five, or six 
inches in diameter. 

In these localities it presents much the same appearances as those al- 
ready described in the account of eczema capitis. 

Impetigo sparsa, which is the scattered form of the eruption, is quite a 
common affection in children of all ages. It differs from impetigo figurata 
in the arrangement of the pustules, which, instead of being confluent or 
grouped closely together, appear singly or in small clusters. It most 
frequently appears on the face and scalp, but is also met with on the ex- 
tremities, being not unfrequent in children, according to Wilson, on the 
bands and feet. 

The eruption appears as small yellow pustules, seated upon an inflarae<l 
base, and attended with more or less itching. The patch frequently presents 
a surrounding circle of confluent vesicles or phlycteniL'. The pustules soon 
break and discharge a sero-purulr-nt fluid, which hanlens into a rugous, 
more or less projecting, friable crust, seeming to consist of diflerent layers 
superimpoK-d one upon the other. When the crusts fall, or after their re- 
moval by topical means, there remains beneath an inflamed surface, which 
may be either excoriated, giving issue to additional fluid and a rcnc^wal of 
the crusts, or dry, and disappearing little by little by the gradual fading 
away of the red color of the spot*. 

Eczema Chronirum. — Eczema infantile, if left to itself, has no natural 
tendency to cure, but usually becomes chronic, as in the adult. 

When the disease passes into this form, no matter what may have been 
the original type of the eczema, the eruption gradually assumes uniform 
and characteristic appemrances. The various forms which have already 
been described are then to be regarded as varieties of acute eczema, while 



910 ECZEMATOUS AFFECTIONS. 

the chronic form is common to them all, and represents the condition into 
which all the acute varieties may merge. 

The skin in chronic eczema is either very much inflamed and thickened, 
presenting excoriations with deep cracks and fissures, which pour out an 
abundant ichorous secretion, or, more frequently, the inflammation is less 
severe, there being much less heat, redness, and infiltration of the skin, 
fewer excoriations and cracks, and a smaller amount of efl"usion. The af- 
fected surface is, in these cases, dry and parched, and constantly throws off" 
a fine furfuraceous desquamation, as in pityriasis, or scales of dried cuticle 
of various sizes, as in psoriasis. 

This form is most common on the scalp, behind the ears, about the neck 
and upper part of the trunk, and in the flexures of the joints. It usually 
lasts for months, and is difficult of cure. It is attended with severe itch- 
ing, which is sometimes so troublesome as to occasion the most distressing 
and uncontrollable restlessness at night. 

Not rarely also, on the application of any exciting cause, the eruption 
will spread from the spots where it has been lurking in the chronic form, 
and invade more or less of the surface, assuming all the appearances of 
acute eczema. 

Diagnosis.- — It must be borne in mind, in making the diagnosis of ec- 
zema, that its characteristic symptoms, which are present in varying pro- 
portion in nearly every case, are redness and infiltration of the skin, 
attended with marked itching; and exudation on the surface, with the 
formation of crusts. 

Eczema simplex when seated on the hands and between the fingers, may 
be mistaken for scabies. The distinction can, however, be made by atten- 
tion to the following points : the vesicles of eczema are flattened and ag- 
gregated ; in scabies they are acuminated, isolated, and entirely distinct. 
There will also be frequently found, in scabies, vesicles on the hips where 
the hand of the nurse from whom the child has caught the disease has 
been placed to support it. In scabies, also, the vesicles present little red 
lines, running off" from their margins, and marking the course taken by 
the acarus ; and lastly, in that disease careful search will almost always 
enable us to detect the insect or its ova, which are infallibly characteristic 
of the disease. 

From sudamina, with which eczema vesiculosum might perhaps be con- 
founded, the latter disease may be distinguished by the facts that the vesi- 
cles constituting sudamina are much larger, that they are discrete and 
scattered, that they are associated nearly always with profuse perspiration, 
and that they are unaccompanied by an inflammatory state of the skin or 
by itching. 

Eczema impetiginoides, especially when affecting the scalp, might possi- 
bly be mistaken for favus, from which, however, it may readily be distin- 
guished by the facts that, in the latter disease, the pustules are imbedded 
in the epidermis, and that the crusts present a peculiar bright yellow color, 
and are of an umbilicated or cup-like shape. 

Favus is also followed by incurable alopecia and is contagious, and 
microscopic examination will detect the peculiar fungus, the achoriou, 



TREATMENT. 911 

upon which it depends, in all of which circumstances it differs entirely 
from eczema. 

Prognoi^is. — Eczema infantile is rarely dangerous to life, though it 
sometimes occasions much distress to the health by the suffering, irritation, 
and especially by the loss of sleep, which it entails. In one insiance, how- 
ever, that came under our observation, of very severe eczema larvale com- 
bined with extensive impetigo figurata, in a child a few months old, the 
disease ended fatally some weeks after the child had boon put under the 
charge of a homivopathic practitioner. 

In the prognosis given by the physician, especially in the instance of ex- 
tensive eczema pustulosum, he should never forget to refer to its probably 
long duration, and to its disposition to return even after an apparent cure 
has been effected. It often last^, in this way, for many months, and some- 
times for one or two years or even longer. This difficulty of cure, and 
obstinate tendency to recur, are often owing to its dependence on some 
constitutional disturbance, or upon derangement of the digestive system. 
It ought, therefore, to be looked upon as the expression of a general dis- 
order ; and its cure will at times be found to depend upon the removal of 
the constitutional fault. 

It is on this account that the opinion has long been popularly entertained, 
that extensive eczema should not be treated by severe local remedies, since, 
if suddenly arrested by such means, the disease might fall with all the 
greater severity upon parts more important to life. 

We no longer, however, attach any importance to this popular apprehen- 
sion, and always endeavor to secure as rapid a cure as possible, by appro- 
priate general and local treatment. 

Treatment. — The remarks which have been already made in connec- 
tion with the causes and constitutional character of many skin diseases, 
will readily suggest the indications which are to be followed in treatment. 
It is necessary to remove the constitutional disturbance which may be the 
essential cause of the affection, to allay the local distress, and to promote 
the healthy vigorous nutrition of the skin. These principles, which guide 
the practice of most dermatologists, are especially insisted on by Mr. Eras- 
mus Wilson, who gives to elimination the first place ; to alleviation of local 
distress the second ; and to restoration of power the third. There are, 
however, some high authorities who regard the constitutional treatment 
in cases of eczema as of very .secondary importance, and rely almost 
exclusively upon local measures. Our own observation has convinced 
us that the most rapid and certain cures can only be effected by a judi- 
cious combination of general and local remedies, either of which, how- 
ever, may under special circumstances, a,ssurae peculiar and paramount 
importance. 

The general treatment of eczema must depend on the state of hcalih of 
the patient at the time, on the extent and activity of the eruption, and on 
its acute or chronic character. 

In mild cases which show but little di.«p<:»»ilion to extend, and are not 
attendefl by much irritation, regulation of the child's diet, and the use of 
the most simple bland applications, will be sufficient.. 



912 ECZEMATOUS AFFECTIONS. 

When the disease is more extensive and attended with much irritation, 
it is necessary to examine carefully into the state of the digestive function, 
and if this be in any way disordered, to endeavor to restore it to a more 
healthful condition. 

When the child is teething, the gums ought to be examined, and, if 
found swelled or inflamed, they should be lanced as often as necessary. 
The diet must be properly regulated, the food being changed if that which 
has been previously taken is found not to be well and completely digested. 

Constipation, if it be present, must be overcome by altering the diet, or 
by the administration of rhubarb, small doses of magnesia, Rochelle salts, 
or sulphur. Purgatives have been strongly recommended by some writers 
in the treatment of eczema pustulosum, but we should advise their use only 
when constipation is present, and in hearty, vigorous children. In most 
cases, the gentlest laxatives, given merely to regulate the bowels, are to be 
preferred. 

If there are evidences of acidity of the stomach, it is well to employ some 
of the various preparations of the alkalies. 

So also when- diarrhoea is present, it should be treated by attention to 
the diet ; and by the administration of a weak castor-oil emulsion, contain- 
ing small quantities of laudanum, when the stools are feculent, but small, 
frequent, and attended with griping ; when they are thin and watery, 
greenish, and composed in part of mucus, the following prescription will 
often prove very useful : 





R.— Tr. Kramerise, 




f^J- 




Tr. Opii, 




gtt. vj. 




Sodse Bicarb., 




• d'h 




Syrup Zingib., 




f^vij. 




Aquse, . 




fjij— M. 


s. 


—A teaspoonful two or th 


ree 


times a day, for children of one and two years 


old. 









When the eruption has persisted for some time, and tends to become, or 
has actually become, chronic, resort must be had to remedies which are 
capable of modifying the constitutional condition of the child. In many 
such cases, the child shows evidences of impaired nutrition, and is weak 
and debilitated ; so that the remedies clearly indicated are those which 
will tend to invigorate the general health and aid in the restoration of 
power. 

The remedy which extensive experience has led us to regard as the most 
useful in all such cases of chronic eczema is arsenic. The preparation of 
arsenic which is best adapted for administration to children is Fowler's 
solution; which we are in the habit of giving in combination with iron, as 
in the following formula : 

R. — Liq. Potassa) Arsenitis, TrjJ xvj ad xxxij. 

Vin. Ferri Amari, 

Syr. Tolutani, aa, f^j. 

Aq. Carui, f^ij.— M. 

Dose — A teaspoonful thrice daily, directly after food, for an infant from six 
months to a year old. 



INTERNAL TREATMENT. 913 

We have never known any serious inconvenience to follow the adminis- 
tration of this remedy, the only annoying symptoms occasionally produced 
being slight gastric irritation aud diarrhtva, and a little puffinoss of the 
eyelids. By giving it immediately after taking food and properly diluting 
it, it rarely causes any gastric irritation, and even should it do so, the 
symptoms rapidly disappear if the remedy be temporarily suspended, or 
given in a smaller dose or less frequently. The mother or attendant, 
should, therefore, be carefully instructed to instantly suspend its admin- 
istration ujK)n the appearance of any disturbance of digestion. The puffi- 
ness of the eyelids, which is one of the earliest and most characteristic 
symptoms of the physiological action of arsenic, is of no alarming import, 
and the remedy need not be instantly suspeuded on account of its appear- 
ance : though it is more prudent, at least, to reduce the dose and frequency 
of administration, and to watch carefully for the occurrence of any further 
signs of the overaction of the drug. 

The period of continuance of this treatment must depend upon the state 
of the eruption, and the manner in which the arsenic is tolerated; if neces- 
sary, however, and if it causes no gastric irritation, it may be continued 
for many weeks or mouths. 

In cases which persist despite local treatment and the internal adminis- 
tration of arsenic, we have frequently found the use of cod-liver oil followed 
by marked benefit. It may be given combined with the arsenic, or, if the 
stomach will not tolerate it in an undisguised form, in the form of an 
emulsion with aromatic*, as already recommended at page 363. 

In cases attended with marked anaemia and debility of constitution asso- 
ciated with a scrofulous tendency, we have obtained good results from the 
administration of the syrup of the iodide of iron. This may be given in 
combination with the compound syrup of sarsaparilla, in the dose of from 
gtt. ij to gtt. V of the former, diffused in from a quarter to a half tea.^poon- 
ful of the latter, three times a day, for children of one or two years of age. 

It is recommended by some authors to administer calomel in consider- 
able and frequently repeated doses in severe eczema. Mr. E. Wilson ad- 
vises 1 gr. of calomel rubbed down with 1 gr. of white sugar or sugar of 
milk, as the dose for the youngest infant ; for a child one year old, a grain 
and a half; for a child two years old, 2 grains ; this dose being repeated 
once a week or oftener, according to circumstances. We have not, how- 
ever, found any necessity for employing calomel as an element of our 
regular treatment, resorting to minute doses of it or of blue pill only when 
the stools are whitish or clay-colored and offensive; under which circum- 
stances it has almost always l>een productive of good effect.'*. 

The diet should be nutritious and strengthening, but, at the same time, 
light and of easy digestion. 

If the appetite is weak and capricious, tonic remedies, as tincture of 
bark,orquinia, in combination with the ferruginous preparation employed, 
ought to be administered. 

In rare cases, where the patient is of full habit, of gross development, 
and of florid complexion, the diet must be somewhat restricted, and a 

68 



914 ECZEMATOUS AFFECTIONS. 

moderate use of cathartic remedies, as small doses of saline laxatives, of 
blue pill and extract of taraxacum, or of sulphur, resorted to. 

Local Treatment. — In mild cases, when the patches of eruption are 
small, and with very little disposition to extend, and the degree of inflam- 
mation is slight, a cure may often be obtained with great ease by the ap- 
plication, twice or thrice a day, of an ointment composed of one part of 
ung. hydrarg. uitratis to three or four parts of simple cerate, or lard ; of 
weak tar ointment ; or of the beuzoated oxide of zinc ointment, as recom- 
mended below ; or it may even be sufficient simply to wash the eruptive 
patches with cool water several times a day, and to anoint them in the 
evening with ointment of cucumbers. 

When the disease is attended with much irritation, the application of 
compresses repeatedly wet with cold water, or with some emollient decoc- 
tion, as of marsh mallow root, flaxseed, sassafras » pith, or slippery-elm 
bark, or the use of warm bread and water poultices, are frequently of the 
greatest service in reducing the heat and irritation, and arresting the 
progress of the eruption. 

The compresses must be repeatedly wetted with the cool applications, 
to prevent the temperature of the liquid from being raised by the heat of 
the body. They may be retained upon the part for several hours at a 
time, or throughout the day, as they may be found to suit the eruption, 
and during the night may be substituted by a dressing of benzoated oxide 
of zinc ointment. 

When warm, moist applications, as poultices, are employed, they should 
always be covered with oiled silk to prevent them from drying. 

The application which we have used with most marked and uniform ad- 
vantage, and which we believe to be the one best adapted to the forms of 
acute eczema, is the benzoated oxide of zinc ointment,^ applied in the 
manner directed by Mr. Erasmus Wilson. 

1 We quote from Mr. Wilson (Diseases of the Skin, 7th Amer. ed., 1868, p. 771), 
the precise directions for preparing this ointment: 

BeWs Formula. 

Ukguentum Oxydi Zinci, Bknzoatum. 

R. — Adipis preparati, ^vj. 

Gummi Benzoini, Pulveris, ^j. 

Liquefac, cum leni calore, per horas viginti quatuor, in vaso chiuso; dein cola per 
linteum, et adde 

Oxydi Zinci, Purificati, ^j. 

Misce bene, et per linteum exprime. 

If it be desired to make this ointment rather more stimulating, we may add a 
little alcohol, as in the following : 



Unguentum Oxydi Zinci, Benzoatum, cum Spiuitu Vini. 

R. — Ung. Oxydi Zinci, Benzoati, ^\]. 

Spiritus Vini rectificati, f^ij. 

Misce, ut fiat unguentum. 



f 



Instead of spirit of wine, spirit of camphor, distilled glycerin, liquor plumbi 



LOCAL TREATMENT. 016 

He directs "that the ointment should be applied abundantly, and gently 
distributed upon the surface until every part of the eruption has a com- 
plete coating; the ointment should be applied night and morning, and if 
accidentally rubbed off, or used upon partx*: exposed to the cjr and fric- 
tion, it may be repeated more frequently. When once applied, the oint- 
ment should be considered as a permanent dressing to the inflamed skin, 
and never removed until the skin is healed, unless special conditions arise 
which render such a process necessary." To secure the permanent con- 
tact with the skin, he recommends that pieces of linen rag, or a small 
garment of linen, be kept constantly upon the parts covered with the 
ointment. 

In cases where the disease has lasted some time, and the discharge has 
dried, so as to form more or less thick and hard crusts, it is absolutely 
essential to get rid of these entirely before any of the applications to be 
hereafter recommended can be efficiently applied. This is especially the 
case in eczema capitis, when masses of scabs have been allowed to collect 
and mat the hair together. The removal of these crusts is best effected 
by the use of thick, moist, and soft poultices, which, when applied to the 
head, should be inclosed in a fine linen rag, in order to prevent the matter 
of which the poultice may be composed from adhering to the hairs. Over 
the outside of the poultice should always be })laced an oiled silk covering, 
to preserve it moist and soft. The poultice may be made of almost any 
unirritating material usually employed for such purposes. One of the 
best is that made of stale bread and water, with the addition of a little 
washed lard or hot almond-oil to keep it soft. The water is preferable to 
milk, as the latter often sours soon after being applied. Another excel- 
lent poultice is one made of ground slippery-elm bark, mixed with a little 
flaxseed or Indian meal, to give it a slightly greater consistence, t^ach 
poultice may be allowed to remain on the part for three or four hours. 

After the crusts have been entirely removed, and the inflammatory con- 
dition diminished by means of the emollient applications above recom- 
mended, the latter may be dispensed with entirely, or during the greater 
part of the day ;-or they may be used only during sleep, at which time 
they are usually best submitted to by the child. At this j-tage of the dis- 
ease it becomes proper to make use of diflTerent lotions and ointments 
intended to modify the action of the diseased skin. 

The number of local remedies recommended in the books for eczema in 
its various forms is, however, so enormous, that we shall refer only to those 
which we have ourselves made trial of and found useful, or which come 
from such sources as entitle them to our attention. 

The choice between the use of lotions or ointments must depend very 
much upon trials made in each particular case, since it will be found that 
some are irritated by all, even the mildest ointments, and Ixar lot ions 
ooly, while in other instances exactly the opposite occurs. 

Amongst the lotions, the most soothing aod beneficial are a weak solu- 

diaceUti!!, Peruvian balMitn, or the juniper Ur nintmont, tniiy he combinftl with 
the benzoated oinlmeot of oxide of sine, in the tame proportion as above, one 
drachm to the ounce. 



916 ECZEMATOUS AFFECTIONS. 

tion of borax containing morphia ; weak lead-water ; a sulphuro-alkaline 
lotion, as the following : 

B — Potass. Carbonat., . ^ss. 

Sulph. Sublimat., . . . . . . • 3J. 

Aquae Fluvial., f^viij. 

Ft. Sol. 

Or weak solutions of bichloride of mercury, gr. ss. to f^j, as Van Swieten's 
liquor : 

R. — Hydrarg. Chloridi Corros., gr. xviij. 

Alcohol, f^iij. 

Aquae Destillat., fjxxix. 

Ft. Sol. 

These lotions may be applied on pledgets of lint wetted with them, or, 
if such prolonged applications prove irritating, they may be used by 
merely washing the part with them for a quarter of an hour each time. 

We have ourselves usually found that ointments afford more relief in 
such cases, and the one which we think the most appropriate, is the oint- 
ment of the benzoated oxide of zinc, rubbed down with a little alcohol. 
Among the other ointments highly recommended, are those containing 
oxide of lead or calamine, or citrine ointment diluted with two or three 
parts of simple cerate. 

When the eruption is confined to a rather small surface and is not very 
acute and rapid in its progress, or when the activity of the inflammation 
has been somewhat subdued, more powerful local remedies may be em- 
ployed. Among these may be mentioned a saturated solution of borax in 
dilute acetic acid ; stronger solutions of corrosive sublimate ; solutions of 
nitrate of silver, of from 2 to 10 grains to the ounce ; or such ointments 
as the citrine, either pure or mixed with an equal amount of lard or sim- 
ple cerate ; or, ointments containing protiodide of mercury : 

R. — Hydrarg. Protiod., # gr- s:ij. 

Camphorse, ........ gr. v. 

Axungise, ........ ^j. — M. 

Apply twice daily. 

Or, calomel : 

R.— Hydrarg. Chlor. Mitis, 9j. 

Camphorse, gr. v. 

Glycerinse, ........ i'5j. 

Ungt. Aquae Rosae, f^j. — M. 

Tar ointment, or either of the zinc ointments, may also be used. 

After the activity of the inflammation has been diminished by treatment 
or by time, and the disease tends to pass into a chronic form, it becomes 
necessary to make use of more stimulating applications than those just 
named. The best of these remedies are those which contain alkaline sub- 
stances, tarry substances, or mercury. 



LOCAL TREATMENT. 917 

The remedy from which we have obtained the most beneficial effects in 
6uch cases, is the spin'tu^t saponafu,<i kalinus of Hebra, which is prepared by 
dissolving soft (potash) soap in alcohol (in the proportion of two parts of 
the soap to one of alcohol\ filtering the solution, and scenting it with 
spiritus lavandnhe, or any other aromatic spirit : 

R.— Saponis Mollis, ,^ij. 

Alcoliolis, ........ I3J. 

Misce, et cohi. 

In the use of this application it is essential, as directed by Hebra, that 
the soap should be firmly rubbed into the eruptive patch by means of a 
piece of flannel or a brush, till the accumulated masses of epidermis are 
removed, and a little blood is seen to ooze from the red base which has 
thus been exposed. 

Other ointments and lotions containing alkaline substances are also rec- 
ommended, such as those containing carbonate of potash, gr. xx to xxx to 
5j of lard (Xeligau), or caustic potash, gr. ij to gr. x to f5J of water. This 
latter application is especially useful in cases where the eruption is confined 
to limited patches, and is attended with much infiltration of the skin. If 
the stronger forms of the solution are used, they should, after being ap- 
plied quickly by means of a brush, be washed off by a large brush wetted 
with pure water. 

Tarry applications also are among the most useful in the chronic form 
of eczema. They may be made in the form of ointments, as the ofiiciual 
tar ointment, or the following, recommended by Rilliet and Barthez as 
successful in their hands : 

R. — Vini Opii, ....... f^ss. 

Picis Liquidie, .^vjss. 

Axungiae, ,^j — M. 

Or, they may be combined with an alkali, as soft soap, as is done in 
Hebra's tinctura saponis viridis cum pice ; which is made by adding one 
part of tar to three of the spiritus saponatus kalinus. 

The tarry ingredient in these may be either common tar; oil of cade 
(oleum cadinum, huile de cade), a product of the dry distillation of the 
wood of the Juniperus oxyredrim; o/eum /ay », obtained from the beech; or 
oleum nisei or hetidiE^ which comes from the bark of the betnla alba. 

When u.sed in the form of soap, it should be rubbed firmlv ovor the 
affected surface, or even be allowed to dry on. 

Dr. Duhring, of Philadelphia (Dis.of the Skin, 187(>, p. l-}i;, recom- 
mends in ca.se3 of localized eczema, with much infiltration of the skin, 
the use of an ointment or lotion containing cau.stic pota>t>8a in addition to 
tar. The amount of pota^^h must be carefully regulated by the suscepti- 
bility of the skin, a.** much irritation may follow if too large a proportion 
be u.<^. 

The forms of mercury best adapted to thi« stage are the nitrate, the 
protiodide, and the mild chloride, which may be combined with lard iu 



918 ^^^W HERPES. 

a larger proportion than that recommended for an earlier stage of the 
disease. 

In cases of eczema tarsi, attended with infiltration of the eyelids, McCall 
Anderson recommends that the eyelashes should be extracted, the eyelids 
everted and a solution of caustic potash grs. v or x to f^ j applied and 
quickly washed off by a large brush. Care should be observed in case 
the edges of the eyelids are adherent in the morning, not to separate them 
rudely, but to moisten them with tepid water or milk and water, so as to 
soften the crusts. Afterwards an application of citrine ointment, diluted 
with about two parts of lard, should be made along the edges of the lids 
night and morning. 



ARTICLE II. 



HERPES. 



Definition; Varieties; Frequency. — Herpes is a non-contagious 
cutaneous disease, characterized by an eruption of vesicles assembled in 
groups on inflamed surfaces, of irregular size and shape, which are sepa- 
rated from each other by perfectly healthy portions of skin. The disease 
is usually acute in its course, seldom lasting more than two or three weeks, 
but it is not, as a general rule, accompanied by any severe constitutional 
symptoms. The separate vesicles composing the eruption last about ten 
days, and then disappear by the absorption of their contents, by the dry- 
ing up of the contained fluid without rupture of the vesicles, or by the 
rupture of the vesicles, the escape of the fluid, and the formation of thin, 
brownish, or yellowish scabs. 

There are several different varieties of herpes, which have been well 
divided by Mr. Wilson into two groups, the phlydeiioid and circinate. The 
phlyctenoid group is characterized by the irregularity of form exhibited 
by the eruption, and includes the variety called herpes phlyctenodes, and 
the local forms, called according to their seat, labialis, nasajis, palpebralis, 
auricularis, prseputialis, and pudendalis; whilst the circinate group is char- 
acterized by the arrangement of the vesicles in circles, and includes the 
herpes zoster and iris. Of these different varieties we shall describe, as 
of importance in children, only the phlyctenodes, zoster, and iris. Herpes 
circinatus, formerly included in this group, will be found described in the 
article on tinea. 

Herpes is quite a frequent disease in children, though one rarely of any 
considerable importance. 

Causes. — The causes of herpes are often obscure and uncertain, and in 
many cases entirely inappreciable. The disease is most common in per- 
sons who possess a delicate and irritable skin. The most frequent and 
most clearly ascertained cause is some disturbance of the digestive func- 
tions, and when there exist, in connection with this condition, irritations 



SYMPTOMS OF HERPES PULYCTENODES. 919 

or inflammations of the respiratory mucous membrane, it is especially apt 
to be developed. Herpes phlyctenodes often follows exposure to a hot 
eun, while herpes labialis is frecjueutly caused by exposure to a cold wind, 
especially when this occurs immediately after leavinir a heated room. The 
latter variety also frequently accompanies coryza, angina, auH stomatitis, 
and appears often as a critical eruption in the course, and particularly at 
the termination, of fevers, catarrhs, and visceral inflammations. 

The usual excitinu causes of the disease are irrcijularities in diet, expos- 
ure of the body while in a heated state to cold and damp, local irritants, 
malarial disease, and bilious disorders of all kinds. 

The cause of herpes zoster is peculiar. The eruption appears, in nearly 
if not quite all cases, to be dejx^ndent upon a morbidly irritable state of 
some nerve-trunk ; which may be the result of simple or rheumatic in- 
flammation, of pressure, of mechanical irritation, etc. 

Herpes Phlyctenodes. — This variety of herpes, unlike the other 
forms of the disease, may appear upon any part of the cutaneous surface, 
and does not assume a determinate shape. It may appear, indee<l, upon 
several parts at the same time. It is usually, however, met with upon the 
upper parts of the body, and particularly the cheeks, neck, chest, and 
arnos. It is rare to observe it on the lower extreniities. 

We believe it to be a rare affection amongst the children of familie^s in 
easy circumstances. The only examples that we have seen have been the 
result of poisoning by the diflTerent kinds of Toxicodendron. 

Symptoms. — The eruption appears in the form of vesicles, usually of 
very small size, looking like mere points, or attaining sometimes the size 
of a pea, which are seated in groups or clusters on inflamed patches of the 
gkin, varying in size from that of a dollar to that of the palm of the hand. 
Sensations of heat, smarting, and itching, are often felt in the part where 
the eruption is about to show itself; and within a day, usually, after these 
symptoms have been ob.«erved, or without them, the disease makes its ap- 
pearance, exhibiting one or more red and inflamed surfaces, of an irreg- 
ular or rounded shape, dotted over with projecting, globular vesicles, 
which are hard, resisting, and, on the first day, transparent, but which l>e- 
corae, in the course of a day or two, turbid or lactescent. The red color 
of the eruptive patch generally extends a short distance beyond the ves- 
icles: the integument between the different patches retain.*, however, in 
all cases, its healthy color and character. A sense of smarting and itch- 
ing accompanies, as well as prece<les, the eruption. On the second day 
of the eruption, the number of vesicles gradually increases, and they be- 
come full and dLotended. About the third or fourth day, the vesiclea 
have become ver>' turbid, and they begin to shrink. About the seventh 
or ei;.'lith day, they are usually transformed, by the drying up of their 
contents, into thin, brownish crusts, which fall off* by des(|uarnatiMn about 
the tenth or twelfth day. There &\m remains, for a few days after the 
disappearance of the eruption, some redness of the surface, which subsides 
little by little. 

This variety of herpes is never accompanied by couMtitutional fymptoma 



920 HERPES. • 

of any severity. A very slight febrile reaction, some languor, loss of ap- 
petite, and thirst, are the only ones worthy of note. 

Herpes Labialis. — This is the most frequent of all the varieties of 
the disease. It is, as its name implies, a disease of the lips. Usually it 
is seated upon the line of junction of the mucous membrane with the in- 
tegument ; but it may affect either the former or latter alone. Though 
generally confined strictly to the lips, the eruption, in some instances, ex- 
tends to the cheeks, chin, or alse of the nose. 

The disease begins generally with redness, heat, smarting, and painful 
tension of the portion of the lip upon which the eruption is about to ap- 
pear. After a few hours, or a day, vesicles begin to show themselves upon 
the inflamed spot, and there is then observed a red, swollen, and shining 
point, upon which is seated a group of vesicles. The tumefaction and 
redness commonly extend some distance beyond the vesicles. The latter 
develop themselves rapidly, until five or six small, rounded vesicles, filled 
with a transparent fluid, are seen. The vesicles remain solitary, or several 
may unite together to form one of considerable size. After the complete 
development of the eruption, the burning pain which existed at first com- 
monly subsides. The contents of the vesicles soon become turbid and lac- 
tescent, and are converted, by the third or fourth day, from a serous into 
a sero-purulent fluid, at which time, also, the accompanying redness and 
swelling have, in great measure, disappeared. Soon after this, brownish 
crusts are formed by the drying up of the fluid of the vesicles, and these 
drop off* usually about the seventh or eighth day. A slight redness re- 
mains for a short time at the point of eruption, and then disappears 
entirely. 

Herpes Zoster. — This variety of herpes is known also by the names 
of Zona and Shingles. It is of much less frequent occurrence, in this city, 
in children, than either the herpes labialis or circinatus. We have seen 
but few examples of it in children, though Rilliet and Barthez state that 
they met with this form and the herpes labialis more frequently than any 
other. 

The name of the disease, herpes zoster, the latter word signifying a gir- 
dle or belt, is derived from the fact that, when it attacks the trunk the 
eruption appears in the form of a half zone, surrounding half the body. 

The most frequent seat of zona is the base of the thorax, the disease 
extending usually, in the form of a cincture, from the mesial line in front 
to the same point behind. It may, however, be developed either above 
or below the part just named, and, under these circumstances, is apt to 
extend towards or down the arm, or towards the thigh and down the leg. 
Still more rarely, it has been observed upon the neck, face, or scrotum. 
It will be found to nearly always follow the course of some nerve tract; 
and is usually confined to one side of the body. The zone formed by the 
eruption is not composed of a continuous line of vesicles, but is made up 
of distinct patches of eruption, all following the same general direction, 
but divided from each other by portions of healthy integument. The 
eruptive patches may be very closely approximated, or they may be sepa- 
rated by considerable spaces of skin untouched by the disease. 



HERPES CIRCINATUS — HERPES IRIS. 921 

The disease is acute in its character, lasting, as a general rule, from one 
to three or four weeks. 

Shingles appear first, after some previous smarting and burning in the 
-kin, and neuralgic pains which may have lasted one or two days, in the 
form of irregular patches of a vivid red color, more or less widely sepa- 
rated from each other, and developed, one after the otlicr, until one-half 
the body is girdled by the eruption. In some instances, the disease ap- 
pears simultaneously at the two extremities of the zone, and is terminated 
by the gradual formation of successive patches between these two points. 
Soon after the appearance of the inflamed patches, numerous small, white 
projections can be seen, by careful examination, upon the red surfaces; 
these increase rapidly in size, and are soon converted into distinct, trans- 
parent vesicles. The vesicles augment in size, and arrive, in the course of 
three or four days, at their fullest development, when they arc about as 
large as small or large peas, or, in some few instances, much larger. At 
this stage of the eruption, the red surface upon which each group of vesi- 
cles is seated extends a slight distance beyond the patch, thus forming a 
kind of areola. 

After pursuing the course just described during four or five days, each 
group of vesicles begins to subside. The redness of the inflamed patch 
diminishes; the vesicles shrink, and become shrivelled; their contents, 
which were transparent at first, become opaque, and finally they dry up 
and form small, dark-brown scabs, which fall ofl^ about the tenth or twelfth 
day, leaving behind reddish spots, which disappear little by little. 

The constitutional symptoms of herpes zoster consist usually of slight 
feverishness, languor, and the signs of gastro-intestinal irritation. The 
local symptoms are pungent and burning pain at the beginning of the 
eruption, and more or less severe tension, and sometimes acute pain, in the 
part upon which the disease is seated, which latter lasts, in some instances, 
throughout the course of the disorder, or even for some considerable time 
after it has disappeared. This neuralgic pain which appears to be de- 
pendent on the implication of a nerve-trunk varies much in intensity, being 
at times slight, and at others very intense. 

Herpes Circinatt^. — This variety of herpos has been caller! also ring 
herpes, herpetic ringworm, and vesicular ringworm ; it will be found de- 
scribed under the name tinea circinata in the article on parasitic diseases 
of the skin. 

Herpf>? Iris. — This is a very rare variety of herpes, and one that we 
have met with in children in Init two instances, although according to 
Duhring (op. ci7., p. 228) it is comparatively frequent in children and 
young people. It begins with small red spot«, which are soon surrounded 
by four or five rings of diflferent shades of redness. About the second day 
of tha eruption, the central red spots present in their centres one or more 
vesicles, and on the third and fourth days, vesicles of very minute size 
generallv appear on the outer concentric rings. After two or three days, 
the fluid contained in the central group of vesicles, which was transparent 
at first, becomes turbid, and alK)ut the fifth or sixth of the eruption, it is 
absorbed, and the disease terminates by a slight desquamation. The 



922 HERPES. 

vesicles formed on the outer ring undergo the same changes as those de- 
scribed as occurring on the central ones. In some instances, the vesicles 
open, and their contents escaping, form small, thin, and brownish scales, 
which fall off in ten or twelve days. 

Herpes iris may attack any part of the body, but is most frequently de- 
veloped upon the face, hands, fingers, and neck. 

According to some dermatologists, as McCall Anderson, herpes iris is a 
parasitic disease and merely a form of tinea versicolor. This view how- 
ever does not appear to us to be correct. 

Diagnosis. — The diagnosis of herpes is seldom attended with any difli- 
culty. The small size of the vesicles, their globular shape, their number, 
their aggregation upon distinct patches of inflamed integument, and the 
slight degree of constitutional disturbance attendant upon the disease, all 
render the eruption unlike any other cutaneous affection, and therefore 
easy of recognition. 

Herpes phlyctenodes might possibly be confounded by an incompetent 
observer with pemphigus. The recollection that the eruption in pemphigus 
consists of distinct bullae, much larger, of course, than the vesicles of herpes, 
while that of herpes phlyctenodes consists of numerous vesicles, much 
smaller than the bullae of pemphigus, and closely dotted over isolated red 
patches, will always serve to distinguish the two affections. It might be 
mistaken also for eczema, when the vesicles of the latter are disposed, as 
sometimes, though rarely, happens, in groups. The distinction may be 
made, however, by attention to the facts that the eczematous vesicles are 
redder, less elevated, scarcely transparent, and that, though arranged in 
groups, they are confluent, whilst in herpes they are always distinct. 

Herpes labialis is not likely to be mistaken for any other eruption. 
Herpes zoster may always be distinguished by the peculiar belted form 
assumed by the eruption, by the arrangement of the eruption in the course 
of some nerve-tract, and by the neuralgic pains which attend it. 

There is but one disease with which herpes iris is likely to be con- 
founded, — roseola annulata. The entire absence of vesicles in the latter 
aflfection w^ill ahvays, however, enable us to make the distinction. 

Prognosis. — The prognosis of herpes is always favorable. It is never 
in itself a dangerous disease, though the variety called zona often causes 
much suffering, and is moreover usually the expression of a considerable 
disturbance of the general health. 

Treatment. — The different varieties of herpes seldom require more 
than the mildest treatment. In all, attention should be paid to the gen- 
eral health. The diet must be regulated according to the state of the 
digestive function. When constipation is present, especially if there be 
some febrile reaction at the same time, gentle laxatives ought to be ad- 
ministered, such as sulphur, magnesia, syrup of rhubarb and magnesia, or 
castor oil. If the skin be sallow, the tongue heavily coated, the breath 
foul, and the stools scanty and light-colored, or very offensive, small doses 
of blue pill in combination with rhubarb, or followed by rhubarb and 
magnesia, would be the most appropriate remedy. Excessive or fre- 
quently-repeated doses of any purgative ought to be avoided, as the de- 



SCABIES. 023 

bility and gastro-intostinal irritation that so often follow such practice, are 
more injurious than the original disease. 

The local treatment of herpes is important, and is, indeed, in many 
cases, all that is necessary. 

Her[H?s phlyctenodes requires nothing more than mucilaginous lotions, 
an occasional warm bath, or the frequent moistening of the eruption with 
a liniment made of equal parts of lime-water and sweet-oil. Herpes labialis, 
if it demand local treatment at all, may be relieved by the use of any mild 
lip-salve ; a very ^ood ointment is one composed of equal parts of (Joulard's 
cerate and simple cerate, with a few drops of glycerin. ^Ir. Wilson 
recommends the following ointment: 

R. — Unguenl. Flor. Sanibuci, ^^j. 

Liq. Plumbi, f^j.— M. 

During the early stage of herpes zoster, the local treatment should be 
such as will tend to allay inflammation and relieve pain. These effects 
may be obtained by applying compresses moistened with some kind of 
mucilage, such as barley-water, or decoction of flaxseed or slippery-elm 
bark, or with simple cold water, or with weak lead-water and laudanum. 
When the eruption is followed by excoriations or ulcerations, and the pain 
is severe, the latter may be allayed by the use of an ointment consisting of 
equal parts of Goulard's cerate and lard, either alone, or containing two 
or three grains of opium, or half a drachm of the watery extract of opium. 
Underwood recommends, when the discharge has subsided, and the scabs 
have formed and become adherent, that they should be anointed twice 
daily with the uug. hydrarg. ammoniat. It is, however, necessary to also 
employ some internal treatment to relieve the neuralgic pains, which arc so 
prominent a symptom. For this purpose, opium must frequently be em- 
ployed. We have also found that the combination of iron, quinia, arscni- 
ous acid and belladonna has aff'orded marked relief in some cases. Phos- 
phide of zinc has been highly recommended by Ashburton Thompson in 
doses of one-third of a grain for an adult. The employment of a galvanic 
current, applied along the tract of the affected nerve has proved very bene- 
ficial. 

Herpes iris seldom requires any treatment. If any be determined on, 
it should consist of alkaline lotions, or of water rendered .slightly a-stringent 
by the addition of alum, or sulphate of zinc. 



ARTICLE III. 



Al;ll>. 



I>i.F iM I !•>> ; .-^^<.^^^i-. \ r.i.'r >>" » — Scabios i« a contagious erup- 
tion of the skin, characterized by the formation of papules, vesicle?, or 
pustules ; the vesicles being pointed, generally discrete, and usually pre- 



924 SCABIES. 

seuting small red lines, of one or several lines in length, running off from 
them. The eruption is attended with severe itching, and is caused partly 
by the presence in the skin of a small insect, called the acarus scabiei, and 
partly by the scratching which the intolerable itching provokes. 

Causes. — Itch is a contagious malady, and is in all probability caused 
only by contact, either immediately with some person laboring under the 
disease, or with articles of clothing worn by an infected individual. 

It is much more frequently met with amongst the poor and destitute, 
whose habits are uncleanly, who live closely packed together in small and 
inconvenient houses, and in whom, therefore, the means of communication 
are more abundant, than amongst the easy classes of society, whose habits, 
and, consequently, liability to contact, are the opposite of those just named. 
It is, however, comparatively rare in the United States, and particularly 
in this city: thus Duhriug met with but 12 cases out of 2472 consecutive 
cases of skin disease. 

The disease usually appears in children in from four to five days after 
the exposure to contagion. In healthy, sanguine children, it often shows 
itself w.ithin a shorter time — after two days — while in those who are feeble 
and weakly, the period of incubation may be even longer than four or five 
days. 

Symptoms. — The first symptoms of itch appear in the part to which the 
cause, a contagious contact, may have been applied. In infants at the 
breast, it is usually first developed on the hips and thighs, as it is those 
parts that are most constantly in contact with the nurses who carry the 
child, and from whom young children generally receive the infection. In 
older children, the disease commonly appears first on the wrists and be- 
tween the fingers, and extends thence more or less quickly to the flexures 
of the elbows, and to the axillae and abdomen. It rarely or never attacks 
the face in adults ; but in children, even this part is not, according to M. 
Richard, exempt. (Trait. Prat des Mai. des Enfants, p. 590.) 

The disease is always attended with severe itching, which, in infants, 
causes uneasiness and fretfulness, and, in older children, violent scratching. 
The itching is increased by the heat of the bed-coverings, and is, therefore, 
most troublesome at night. The eruption appears in the form of more or 
less numerous vesicles, which are small, discrete, acuminated, and trans- 
parent at the top. The vesicles are at first of a faint rose color, and they 
contain a viscid transparent serum. Their number is variable, being 
sometimes very abundant, and at others sparse. They either open spon- 
taneously, or are soon broken by the fingers or clothes, and are followed 
by small, thin, slightl}^ adherent scabs. In some instances the action of 
the nails causes slight effusions of blood, which dry into small bloody scabs, 
like those of prurigo, thus embarrassing to a certain extent, the diagnosis 
of the disease. Sometimes, particularly when the inflammation attendant 
upon the eruption, or that caused by scratching, is marked, there are, inter- 
mingled with the psoric vesicles, pustules of impetigo, or perhaps papules 
of lichen, which tend, like the sanguine crusts just alluded to, to render 
the diagnosis difl^cult. Indeed it is not strictly correct to define scabies, 



i 



DIAGNOSIS. 925 

as was formerly done, as a vesicular affection, since the eruption is papular 
in a very large proix>rtion of cases. 

When a recent vehicle is carefully examined, there may generally ho 
observed running oti' from it, in a straight, curved, or zigzag direction, a 
whitish or reddish line, like that produced hy the scratch of a pin. This 
line marks the course of the fecundated female of the acarus scabiei in its 
burrowings under the epidermis, and is called the cuniculus, or burrow. 
It varies in length from one or two, to five or six lines. At the point where 
it terminates opi>osite to the vesicle, there is usually to be seen a small 
rounded projection, deej>er in color than the rest of the euniculus, beneath 
which lies the insect. The acarus can often be f«)und at this spot, and re- 
moved, by carefully introducing horizontally under the epidermis tiie point 
of a small needle, and by manipulating so as to take ofl' a small layer of 
the epidermis. The insect clings to the point of the needle, and can then 
be extracted from its lodgment. 

The number and extent of the vesicles vary greatly in ditlerent subjects. 
In some they are confined to limited surfaces, while in others, and partic- 
ularly in robust, sanguine children, and in those who are neglected and 
imperfectly cleansed, they extend to many different parts, or over the 
greater part of the body. 

Itch occasions in children much irritability and suffering, and when 
neglected may injure seriously the general health, and cause emaciation 
and debility. 

The acarus scabiei is an arachnoid insect, varying, according to Mr. 
Wilson's measurements, between tIt and A of an inch in length, and 
between 3^3 and i\ of an inch in breadth. It is of a whitish and shin- 
ing color, when examined with the naked eye, of a globular form, and is 
provided with eight legs, four anterior and four posterior. A most accu- 
rate and minute account of the structure of the insect is given by Mr. 
Wils<m in his work on diseases of the skin (7th Amer. ed., p. 7.39). Be- 
sides the female, which is found as before stated, at the extremity, the 
euniculus contains a varying number of ova, rarely more than twelve or 
fourteen ; there are io addition numerous little oval or round blacki.^^h 
spots, which are supposed to be excrement. These ova are about sdo of 
an inch broad, and jio of an inch in length, though their size varies ac- 
cording to their age. After the escape of the acarus the shell appears 
shrivelled, with two slits in it. 

DiAfJNOHLs. — The most characteristic marks of itch are the presence of 
the cuniculi and of the insect which causes the disease. If the acarun t)r 
its ova can be extracted from the skin, there will remain, of courw;, no 
doubt ; and if the cuniculi be distinct and numerous, the diagnosis becomes 
almost as certain as when the insect itself is obtained. Before endeavor- 
ing to detect the cuniculi, it is always advisable to make the patient wash 
the part thoroughly. 

In doubtful cases, it has been recommended by Gull and Hilton Fagge 
to search for the ova in the crusts or the thickened and undermined 
cuticle in the neighborhood] of the vesicles. In order U) detect these, a 
small piece of the crust should be boiled in a s^ilution of caustic soda, 3m. 



926 SCABIES. 

to f5j of water, until it is in great part dissolved ; the fluid should then be 
allowed to settle, the supernatant part decanted and the deposit examined, 
which will, in cases of true scabies, be generally found to contain larvae, 
ova, or egg-shells. 

When, on the contrary, the insect cannot be found, and when the cuniculi 
are absent or not distinct, the diagnosis becomes more uncertain. The 
diseases with which it is most likely to be confounded are eczema simplex, 
prurigo, and lichen simplex. From the former it may usually be dis- 
tinguished with certainty by attention to the following points. In eczema 
the vesicles are flattened, or globular, scarcely raised above the surface, 
and they are collected together in clusters ; in itch they are acuminated, 
elevated, and either entirely distinct, or much less confluent than in eczema; 
in eczema there is a sensation rather of pricking than itching, whilst in 
itch the sense of itching is severe and distressing ; and lastly, itch is com- 
municable by contact, whilst eczema is never contagious. 

Prurigo begins with papules, which always remain such. The scabs in 
prurigo are small and black, consisting of coagulated blood, caused to 
exude by the rubbing off* of the top of the papule ; while in scabies the 
scabs are more like thin, yellowish, and friable scales. The seat of the 
two eruptions is different. Prurigo is developed upon the back, the 
shoulders, and upon the extensor surfaces of the limbs ; while itch ap- 
pears first about the thighs and buttocks, between the fingers, or about the 
flexures of the joints. Lastly, prurigo is never, itch always, contagious. 

Lichen simplex is a papular disease, in which the papules are closely 
agglomerated, while in scabies the papules, if present, are 'conjoined with 
vesicles, and are discrete. Lichen sometimes affects the hands, and might 
then be mistaken for itch ; but in the former the eruption aflTects the dorsal 
surface of the hands, while in the latter it appears in the interspaces of the 
fingers. Lichen is never attended, as itch always is, by severe pruritus. 
Attention to these points of diflTerence will almost always render the 
diagnosis of the two diseases very easy and certain. 

When, as sometimes happens, scabies is intermingled with other erup- 
tions of the pustular, papular, or vesicular kind, the diagnosis can be 
arrived at with certainty, only by careful attention to the cuniculi, or by 
the detection of the insect. When neither of these characteristic condi- 
tions are present to mark the true nature of the disease, there will always 
remain some doubt as to the diagnosis. 

Under these circumstances, however, it is advisable to treat the case as 
one of scabies, since the specific remedies for this affection will not be in- 
jurious, even if they do not speedily cure the eruption. 

Prognosis. — Itch is a mild disease, which never disturbs the health 
seriously. 

Treatment. — If the inflammation produced by scratching be very 
severe, it may be necessary to allay it by emollient applications, though 
this rarely happens. . 

In children, as in adults, the best treatment of itch is the use of sulphur 
by inunction. The ungt. sulphuris of the American Pharmacopoeia, con- 
sisting of one part of sulphur to two of lard, should be well rubbed into 



oJ- 




o'J- 




5v. 




f5ss.- 


-M. 


,VJ- 




J>i- 




5^''ij- 


— M. 



TREATMENT. 927 

the skin before a fire, morning: aiul ovoniiifr, for two days. The cliiKl 
-hould he kept in a flannel gown, and in bed, during this treatment. On 
ilie morning of the third day, the skin may be waslied clean with soap and 
water, or by immersion in a warm bath. This plan rarely fails to efleet 
a cure. Should it happen, however, to fail, the treatment mujt be re- 
peated. Before the application of this or any of the other ointments, the 
-Lirface should be well scrubbed with soap and hoi water, so as to cleanse 
and soften the skin. 

It also increases the effect of the sulphur, to conjoin with it some alka- 
line substance, as in the various sulpho-alkaline ointments and lotions, of 
which the following are among the best: 

Unq. Sulpuuris cum Potassa (Wilson). 

R. — Sulphuris Sublimati, ..... 

Potassa? Carbonatis, 

Unguenti Benzoati, ...... 

Olei Anthemidis Esscntialis, .... 

Uelmerich's Formula. 

B- — Sulphuris Sublimati, ..... 

Potassie Carbonatis, ...... 

Adipis Preparati, 

VLemingkx's Forymda. 

R. — Calcis Vivi, ,^ij. 

Sulphuris Sublimati, ...... ^^iv. 

Aqua Fontwnae, ^o^^- 

Boil in an iron vessel, and stir with a wooden gpatula to a perfect union. 

These are all quoted in the proportions directed for adult,s, which are 
much too active to be applied to the delicate skin of children ; they should 
therefore be diluted one-half at least. 

Anderson recommends the use of oil of cade or tar, comljiiicd with the 
sulpho-alkaline ointments. 

As the use of the sulphur ointment is sometimes objected to in j)rivate 
families, on account of its disagreeable odor, various substitutes have been 
recommended. Mr. Wilson states that he found camphor di.ssolved in oil, 
in the proportion of one drachm to the ounce, answer every purpo.se of 
• radicating the di.sease ; and Dr. Coley (Prac. Treat, on I)'n^. of C/ilidren, 
Phil, ed., 101 J speaks highly of an ointment compo.'^cd of a drachm of 
iodide of pota.ssium to an ounce and a half of lard, of which a little is to 
be applied all over the body, except the head aud face, every night. 

OintmeDts containing carbolic acid or petroleum are also used with good 
effect. 

The use of stavcsacre and hellebore has lately been revive<l, and aj)- 
parently with good success; and Anderson highly rwommend.-* an oint- 
ment made by melting together one part of liquid sfyrax with two of lard. 

The di.*^;-a.**€ rarely requires any ccinstilutional injitmi'nl. If, however, 
any complication exist, or the general heulili be deranged in any way, 



928 PEMPHIGUS OR POMPHOLYX. 

such measures as may be necessary for the removal of either of these con- 
ditions should be employed, in connection with those proper for the specific 
disease. 



CHAPTEE III. 

BULLAE. 

AETICLE I. 

PEMPHIGUS OR POMPHOLYX. 

Definition ; Synonyms ; Varieties ; Frequency. — Pemphigus is an 
eruptive disease, characterized by the presence on one or several parts of 
the body of more or less numerous bullae of considerable size, nearly always 
isolated, resting upon circular or oval erythematous j^atches, about as large 
or somewhat larger than the bases of the bullae themselves. The bullae 
form in the course of a few hours, and contain at first a limpid serum, 
which soon becomes reddish or turbid ; they terminate by desiccation and 
the formation of thin crusts, or by rupture and the escape of their contents, 
when there remains behind a superficial ulceration. 

Authors formerly described numerous varieties of this disease, and gave 
to some of them the title of pompholyx. Of late years, however, these 
have been reduced to a few forms, and we shall confine our remarks to 
those most apt to occur in children. The only variety which is really im- 
portant in children is the pemphigus acutus. The pemphigus chrouicus, 
a dangerous and not unfrequent variety in old people, is so rarely met 
with in early life, as to make it unnecessary for us to describe it. Another 
species of bullar eruption, formerly called pemphigus infantilis, is now 
more properly classed as rupia escharotica, under which title w^e shall give 
an account of it. 

Pemphigus is not unfrequently met with in young children who become 
the inmates of hospitals, almshouses, and foundling hospitals, and amongst 
the poor and destitute classes of large cities. Still it cannot be said to be 
a frequent disease. 

Causes. — The causes of pemphigus are often obscure or entirely inap- 
preciable. It is usually supposed, however, to depend, in children, upon 
the influence of the act of dentition, on disturbances of the gastro-intestinal 
tube brought about by improper food or overfeeding, and on general dis- 
order of the nervous system. It is one of the most frequent eruptions in 
congenital syphilis (see p. 877), and is not rarely present at birth in such 
cases. 

Symptoms. — Acute pemphigus may be confined to a very small portion 
of the cutaneous surface, or it may affect several regions of the body at 



(J 



SYMPTOMS — DIAGNOSIS — PROGNOSIS. 029 

once. It is usually attended with symptoms of constitutional disturbance, 
which, esj)ecially in very young infants, may be sli^jjht, consisting merely 
.f general uneasiness, languor, and some acceleratiDU of the pulse; or they 
may be severe, exhibiting in such case;? a dry and burning skin, frequent 
pulse, thirst, and loss of ap[)etite. 

After the above constitutional symptoms have lasted one, two, or three 
lays, the eruption makes its appearance in the form of small circular red 
-pots, which increase in size, and soon exhibit a bleb or bulla rising in the 
middle or over the whole of the red spot. The vesicle commonly appears 
a few hours after the red patch, and consists of an elevation of the cuticle 
by au effusion of serum beneath it. The bulla rapidly distends by the in- 
crease of the serous etlusion, until it attains the size of a pea, a hazelnut, 
or a large walnut. It is of a circular or oval form, and may be confined 
to the centre of the erythematous surface on which it rests, being sur- 
rounded in such cases by a more or less wide red line of inflammation, or 
it may occupy the whole or nearly the whole of the red patch, under 
which circumstances it entirely conceals the latter, or is surrounded by a 
very narrow red ring. The color of the areol.*e around the bulhe is very 
bright during the first day of the eruption, while the integument between 
remains perfectly healthy. 

The fluid contained in the bulla? soon becomes turbid ; the bullie become 
wrinkled, and usually burst after one or two days, and are replaced by thin 
yellowish or brownish scabs. The crusts begin to form before the redness 
of the integument has disappeared. In some instances the bulljc do not 
l»reak, but their contained fluid becomes yellowish in color, and then 
turbid; it diminishes by absorption, and, at the end of about a week, dries 
into a thin dark-colored scab. The crusts usually fall off in the course of 
two or three weeks, leaving the skin beneath of a reddish color, but in 
other respect* healthy. The whole duration of the disea.se is commonly 
from one to three weeks, the time in each case varying with the mode of 
the eruption ; when all the bulhe appear simultaneously, seldom lasting 
more than one or two weeks; while in cases in whi( h tluy appear at suc- 
ceasive periods, lasting three or even four weeks. 

DiAfiNOsir?. — The diagnosis of [)emphigus acuius is seldom difficult. 
The large isolated bulhe, seated on inflamed patches of the integunient, 
filled with transparent serum, and followed by thin lamellated scabs, are 
unlike any other kind of eruption. From rupia, the other form of bullar 
disease, it is to be distinguished by the smaller number of blebs in the 
former, by their greater flatnes-s, and by the facts that th(?se are followed by 
true ulcerations, and by thick and prominent scalw. 

pROGSoeis. — Acute pemphigus U rarely dangerous when it exists with- 
lications. When, however, it i^ very extensive, and accompanied 
re constitutional symptoms, and partirujarly when it exist-s in con- 
nection with other dij^eases, or occurs in a child whojHj health has l>c«en 
broken down by unwholesome hygienic influence**, it may ansumc a danger- 
ous character, and the prognoois should, therefore, always l>e guarded 
under such circumstances. 

69 



930 RUPIA. 

Treatment. — Simple acute pemphigus requires, as a general rule, no 
other treatment than attention to diet, and regulation of the digestive 
function. When constipation is present, this should be overcome by 
means of simple enemata, or by the use of some mild laxative, as manna, 
spiced syrup of rhubarb, or very small doses of castor oil. If the dis- 
charges be too frequent, they should be restrained by the use of opium in 
doses proportioned to the age of the child. In young infants, it will often 
be found that the gastro-intestinal secretions are of an acid and irritating 
character. This condition may be treated with small doses of paregoric 
or laudanum, combined with lime or magnesia-water, or with soda. The 
diet must be managed according to the state of health of the child. For 
an infant, a good breast of milk is, of course, the best treatment in the 
world. For older children, the diet ought to be light and unirritating, 
but, at the same time, nourishing and strengthening. 

The local treatment should consist, in the early stage, of an occasional 
warm bath. When the bullae have fully formed, they ought to be punc- 
tured, and the fluid gently pressed out, care being taken not to remove 
the cuticle, as this forms the best possible dressing for the inflamed integu- 
ment. When the bullae are followed by excoriations, these may be dressed 
with an ointment consisting of equal parts of Goulard's cerate and simple 
cerate, made a little soft by the addition of glycerin, or with carrot or 
elder-flower ointment, or with Turner's cerate. Much relief may also be 
gained from the use of water dressings by means of cloths. 

When the child shows signs of debility during the progress of the dis- 
ease, and also when the eruption tends to assume a chronic course, the 
treatment ought to be tonic and invigorating. It should consist in the 
use of a nutritious diet, and in the exhibition of tonics, as Huxham's 
tincture of bark, in small doses, quinia, arsenic, cod-liver oil, or in the use 
of wine-whey, or small quantities of brandy. 



AKTICLE II. 



RUPIA. 



Definition ; Varieties. — Rupia is an eruptive disease, characterized 
in its early stage by distinct, somewhat flattened bullae, of more or less 
considerable size, containing at first a serous, and then a purulent or 
blackish fluid : at a later period the disease exhibits very thick scabs, and 
still later, ulcerations. 

There are three varieties of this eruption : rupia simplex, rupia prom- 
inens, and rupia escharotica. The latter variety was formerly described 
under the title of pemphigus infantilis, and pemphigus gangrenosus, and is 
known in Ireland under the different names of white blisters, eating hive, 
and burnt holes. It is the most important variety of the disease in young 
children. 



CAUSES — SYMPTOMS — RUPIA ESCHAROTICA. OHl 

Causes. — Rupia is most apt to occur in weakly, badly nourisliod, ami 
scrofulous children, and seems to depend, therefore, upon that state of de- 
bility and exhaustion of the general health, which results from exposure 
to unfavorable hygienic conditions, which follows exhausting diseases, or 
which exists as a consequence of some hereditary taint. 

Symptoms. — Bupia simplex begins almost always on the inferior ex- 
tremities, or more rarely on the trunk or arms, without previous inflam- 
mation, in the form of small, flattened bulla; of about three or four lines 
in diameter. The bullie contain at first a serous and transparent fluid, 
which soon becomes thicker, and is converted into pus. At an early 
period they shrink and become wrinkled, their contained Huid hardens 
and is converted into rough, brownish scabs, which are always thicker at 
the centre than on the edges, and which leave beneath, after their fall, 
superficial ulcerations. These ulcerations either soon cicatrize and disap- 
j)ear, or are covered by fresh scabs. After the fall of the final scabs, there 
yet remain, for some time longer, dark-brown or livid spots, which gradu- 
ally fade and disappear. 

Jhipia promiueus exhibits the same general characters as the preceding 
variety, but with more marked and peculiar features. The eruption com- 
mences witk a circumscribed inflammation of the skin, on which inflamed 
spot soon appears a bullie filled with yellowish serum, or sometimes with 
a blackish fluid, which rapidly hardens into a brownish or blackish 
wrinkled crust. The crust is surrounded by an erythematous areola, 
formed by the extension of the cutaneous inflammation beyond the cir- 
cumference of the scab. Upon this areola a fresh elevation of the cuticle, 
by purulent deposit, often takes place, which, by its desiccation, adds to 
the size of the crust. This successive increase at the margin of the scab 
enlarges it in breadth, and, at the same time, raises the height of its cen- 
tre, so as to give it a peculiar and characteristic ap})earance, and causes it 
to resemble very closely the shell of a limpet or oyster. The scabs thus 
forme<l usually adhere to the surface beneath with much tenacity, and re- 
main attached for a variable, and, as a general rule, considerable length 
of time. When at length they fall off, or are removed, there are left 
beneath ulcers of variable depth and extent, which are either covered by 
fresh crusts, or, as more frequently hap[>en8, remain open, presenting a 
foul surface of a livid red color, which thickened edges. The ulcers are 
difficult to heal, and, after cicatrization, leave livid or purplish stains, 
which often remain for months. The number of bulla is usually small, 
there being generally one at ita height, and one or two about to apixjar, or 
on the decline. 

Rupia Escharotica. — This variety of rupia, formerly described aa 
belonging to the class pemphigus, and then calle*! pemphigus infantilis 
and gangrenosus, differs in some respects from the other varieties of ruj)ia, 
and particularly in the absence of the thirk and projecting rrustJ*, wliich 
characterize rupia simplex and prominens. It occurs chiefly amongst 
cachectic children, appearing usually in the period between birth and 
the first dentition. It is seate<l generally upon the neck, chest, abdomen, 
scrotum, or inferior extremities. 



932 RUPIA. 

The eruption begins in the form of purplish or livid spots, raised slightly 
above the level of the skin. Upon these spots the cuticle is soon elevated 
by a serous fluid, so as to form small bullse, which become rapidly larger, 
until they attain their full size. The bullae are smaller than in the other 
varieties of rupia ; they are irregular in shape, flattened on the top, and 
are surrounded by purplish areolae in the early stage of the eruption ; the 
fluid they contain becomes, at an early period, turbid and dark-colored, 
or almost black. The bullae soon wrinkle, burst, and leave ulcerated sur- 
faces, which are painful, often covered with sloughs, secreting a sanious 
and fetid pus, and diflScult of cure. 

Soon after the formation of the ulcers, a fresh crop of bullae, forming 
a new eruption, often appears and passes through the same phases as the 
first, thus prolonging and exteflding the disease. This form of rupia is 
attended with much pain, with fever, sleeplessness, restlessness, and often 
ends fatally from the severe and continued irritation kept up by the dis- 
ease. In cases ending favorably, the process of cicatrization is always 
slow and difficult. 

Diagnosis. — Rupia is likely to be confounded only with pemphigus and 
ecthyma. Pemphigus is to be distinguished from rupia by the larger size 
and greater distension and prominence of its bullae ; by the fact that the 
contained fluid of the latter is serous and transparent in pemphigus, in- 
stead of being turbid and sanguinolent, as in rupia ; by the diflferent char- 
acter of the crusts, which, in pemphigus, are thin and lamellated, while in 
rupia they are thick and rugous ; and, lastly, by the deep and unhealthy- 
looking ulcerations that follow rupia. 

Ecthyma is unlike rupia in being a pustular disease from the first. 
Moreover, the pustules of ecthyma are surrounded by a highly inflamed 
areola, which is not the case in rupia, while the crusts in the former dis- 
ease differ from those in the latter, in being smaller, harder, more irreg- 
ular, and more adherent. 

Prognosis. — Rupia simplex and prominens, though tedious and slow 
of cure, seldom prove fatal, while rupia escharotica is always dangerous, 
and in very weakly children, especially when these are exposed to bad 
hygienic conditions, very generally ends unfavorably. 

Treatment. — The most important point in the treatment is to attend 
to the hygienic state of the patient. ^Yhen the child is living in an un- 
healthy house, or a close and confined room, it should be removed, if pos- 
sible, to a more salubrious position, or to a larger and well-ventilated 
room. The diet ought to be such as to invigorate the strength, and pro- 
mote the nutrition of the body. For an infant who is fed upon artificial 
food, or who is suckling a nurse of doubtful health, the best remedy in the 
world is a fresh and full breast of milk. If a nurse cannot be procured, 
the diet must be most carefully regulated in accordance with the princi- 
ples already detailed in full in the article on thrush, at page 324. While 
the diet is thus attended to, it is necessary to watch the state of the diges- 
tive organs, and if there be either constipation or diarrhoea, these must 
be overcome by suitable remedies. Tonics and stimulants are always ad- 
visable in this disease, and may consist either of brandy or wine, given 



ECTHYMA. 933 

alone, or in connection with Huxham's tincture of bark, extract of cin- 
chona, small doses of nuiuia, iron, cod-liver oil, or any other remedy of 
this kind that may be preferred. 

Rupia simplex and prorainens are to be locally treated in the early 
stage by opening the bulla? so soon as they form, and covering them with 
dry lint and a light bandage, or with the water-dressing. The ulcerations 
that follow the bulhv may be treated with Goulard's ointment, applied on 
pieces of fenestrated lint, and by washing occasionally with lime-water, 
or with weak solutions of alum, copper, zinc, or nitrate of silver. At a 
later period of the disease, when the ulcei*ations are covered with the char- 
acteristic thick crusts, these are first to be removed by means of poultices 
of bread and water, or flaxseed meal, and the surfaces beneath them 
treated with the applications recommended above. When the ulcerations 
are very obstinate and difficult to heal, they should be modified by occa- 
sional touchings with nitrate of silver, either pure or in strong solution, or 
with dilute nitric or muriatic acid. 

Billard recommends that the ulcerations should be dusted with pow- 
dered alum or cream of tartar, and Rayer also speaks very highly of the 
last-named application. 

Dr. Stokes found that the best treatment in epidemic rnpia escharotica 
was an ointment of the scrophularia nodosa, made by stewing the small 
leaves of the plant in as small a quantity of uusalted butter as may be 
sufficient to prevent their scorching. The ointment is to be warmed until 
it becomes quite thin, and then applied by means of a brush, after which 
the surfaces are to be covered with lint smeared with the same ointment 
The dressing is to be renewed every six hours. 



CHAPTER IV. 

PUSTULES. 

ARTICLE I. 

ECTHYMA. 

Definition; Synonyms; Vakietiks. — Ecthyma is an eruption char- 
acterized by prominent, rounded, and usually discrete pustules of con- 
siderable size, with hard and inflamed bases. The pustules are followed 
by thick, brownish crusts, which leave on their fall a ro Idi-h mark, or 
more rarely a superficial ulcer or a true cicatrix. 

Ecthyma has been calle<l also phlyzacia. Then- ai.: i»\m >.iiiiM>.»i 
the disease to which children are subject, edhyma vulyare, or arntiim, and 
ecthyma inf untile. 

CAtsErj. — The most frequent causes of ecthyma arc the application of 



934 ECTHYMA. 

irritating substances to the skin, such as croton oil and tartar emetic 
ointment, and the presence of other eruptions upon the skin, particularly 
small-pox, measles, scarlet fever, herpes, or scabies. The causes just 
Darned give rise to the variety called ecthyma vulgare, which, it may be 
well to state in this place, is of an acute character, and has therefore been 
called by some writers ecthyma acutum. The other variety of the disease, 
ecthyma infantile, is a chronic affection, and occurs almost always in feeble, 
badly nourished, and cachectic children, and in those whose health has 
been injured and broken down by exhausting diseases, and particularly 
by disorders of the gastro-intestinal apparatus. 

Symptoms. — Ecthyma vulgare occurs most frequently on the extremities 
and neck, and more rarely on the trunk of the body. It appears in the 
form of small, red, and circumscribed spots, projecting above the surface 
of the skin, hard to the touch, and accompanied by smarting and often 
severe pain, and by soreness on pressure. The centre of the spots is soon 
elevated into a pustule, filled with a purulent fluid. The size of the pus- 
tules varies, but is usually about that of half a pea. Each pustule is 
generally surrounded by a hard base of a bright red color, constituting an 
areola, while, in some instances, the whole of the red elevation is covered 
by the pustular formation. The pustule remains unchanged usually for 
three or four days, and more rarely for a week, and is then converted, by 
the drying up of the effused fluid, into a thinnish brown scab, which drops 
off after a few days, and leaves a congested purple spot that remains for 
some time longer. In other instances, the pustule breaks and leaves a 
small ulceration which terminates with a slight cicatrix. The eruption is 
commonly successive, and is seldom accompanied by any febrile reaction. 

Ecthyma infantile is much more frequently met with than the other 
variety of the disease, and occurs in a single, or oftener in successive 
eruptions, in feeble, badly nourished, and cachectic children. It appears 
on the neck, shoulders, arms, and chest, and especially upon the lower 
extremities. It is often connected with some chronic disorder of the diges- 
tive or respiratory apparatus, and is developed during the state of debility 
and exhaustion to which children are reduced by those affections. 

The pustules of ecthyma infantile are of variable size, some being small, 
and others as large or larger than a sixpence. They are circular in form, 
and surrounded by an areola of a red or purplish tint ; the fluid which they 
contain is generally not very thick, and is of a dark and sanguinolent ap- 
pearance ; they terminate by the formation of a dark and adherent crust, 
by absorption of the contained fluid and a kind of desquamation, or by a 
bloody excoriation, or true ulceration, which are followed by a deep stain 
upon the skin or a true cicatrix. 

Diagnosis. — Ecthyma is more likely to be confounded with rupia than 
with any other disease. The pustular character of ecthyma from the very 
beginning, will, however, almost always enable us to distinguish it from 
the broad and distended bullae of rupia, filled with seropurulent fluid ; 
and the difference between the two becomes still more marked, when we 
recollect the hard and inflamed bases on which the pustules of ecthyma 
rest, and the shapeless crusts and superficial excoriations of that disease, 



I 



PROGNOSIS — TREATMENT. 935 

instead of the projecting, rugous, and imbricated scabs, and dee]> ulcer- 
ations of rupia. Ecthyma is not at all likely to be mistaken for the small 
and numerous pustules of impetii^o, or the umbilicated ones of small-pox. 

Prognosis. — Ecthyma is never a dangerous disease in it<elf. If any 
danger accompany it, it arisen rather from the enfeebled and disordered 
state of the general health under the influence of which it is produced, 
than from any injury caused by the eruption. The jirognosis mu-^t depend, 
therefore, upon the state of the general health existing during the atUick 
of the disease. 

Treatment. — In both varieties of ecthyma, attention to the general 
health of the patient constitutes the most important point in the treatment. 
In the acute form, mild laxatives, small doses of some alterative, as the 
hydrargyrum cum creta or sulphur, the use of a nutritious and wholesome, 
and especially of an unstimulating diet, and the local application of mu- 
cilaginous infusions, or of a mild and cooling ointment, as Goulard's cerate, 
Turner's cerate, or the carrot, cucumber, or elder-flower ointments, with 
occa^iional warm bathing, are all that the ca.«e demands. In the ecthyma 
infantile, the attention of the physician should be directed towards the 
restoration of the general health, which, as stated above, is always more 
or le^s deteriorated. As this deterioration depends usually upon the expo- 
sure of the child to unwholesome hygienic influences, and a consequent 
unhealthy state of the digestive and nutritive functions, it is of primary 
importance that these should be early attended to. The patient ought to 
be placed in a healthy and well-ventilated apartment; the clothing must 
be regulated according to the age of the child, and the season of the year; 
and, what is most important of all, the diet ought to be such as is digest- 
ible, suitable to the age, and, at the same time, nourishing and strength- 
ening. The internal remedies must consist of tonics in all cases, and 
when the digestive power and general strength are reduced much below 
the normal standard, of stimulants. The best stimulant is old and pure 
brandy, either given mixed with water, three or four times a day, or com- 
bined with the food. The best tonics are, in most cases, some preparation 
of iron, and the one we prefer is the iodide, given mixed with syrup of 
ginger, or, when the bowels are not too irritable, with small quantities of 
the compound syrup of sarsaparilla, or cod-liver oil. When, for any 
reason, iron is not given, quinia, or extract of cinchona, may be sub.sti- 
tuted. While these remedies are being employed, or prior to their ad- 
ministration, the gastro-inte«tinal functions ought to he carefully regulated 
by the use of mild laxatives when the bowels are constipated, or by some 
kind of astringent when they are loose and disordered. 

The external or local treatment must consist in the use of mild demul- 
cent applications, or of soothing or cooling oi nt men ti*, during the pustular 
stage of the eruption. When unhealthy excoriations or ulcerations fol- 
low the pustules, these may be brought into go<^Ki condition by the employ- 
ment of weak solutions of nitrate of silver or sulphate of zinc, or of a 
very weak lotion of nitric or muriatic acid. 



936 STROPHULUS. 



CHAPTER Y. 

PAPULES. 

ARTICLE I. 

STROPHULUS. 

This is a form of papular eruption which some writers regard as a 
variety of lichen, giving to it the name of lichen strophulus. It, however, 
differs somewhat in its characters from the lichen of the adult, and, as it 
is peculiar to children, deserves a separate consideration. 

Strophulus is a disease affecting chiefly infants at the breast, character- 
ized by a more or less extensive, and sometimes a general eruption of pap- 
ules, which are whiter or redder than the surrounding skin, and are accom- 
panied by more or less irritation and itching. 

Its causes are various disturbances of the digestive apparatus in very 
young infants, and in older ones the effort of the first dentition. Tilbury 
Fox {Skin Diseases, New York, 1873, p. 155) regards strophulus as the 
result of hypergemia of the sweat glands, and inclines to consider it as 
due to excessive clothing, to overheated rooms, changes of weather, etc. 

Varieties and Symptoms. — The strophulus intertindus, or red gum, 
consists of an eruption of prominent pimples of a vivid red color, scat- 
tered here and there over different parts or the whole of the body, and 
intermingled with small erythematous patches. The eruption remains 
upon the skin for some time, the papules disappearing and reappearing 
in successive crops, for a week or two, or more, until they terminate by 
desquamation. It is most common upon the cheeks, backs of the hands, 
and forearms. 

In strophulus confertus, the papules are much smaller, more closely ag- 
gregated, much more numerous, and more confluent, than in the first 
variety, and they constitute a more severe eruption. It may be distrib- 
uted over the whole surface, but is more commonly limited to a single 
spot, or to several regions, as the face, breast, or arms. The eruption is 
less vivid, but more lasting than that of the strophulus intertinctus, and 
usually reaches its height in twelve or fourteen days, and then subsides. 

In strophulus volaticus, the papules, which are of a vivid color, are. dis- 
posed in small, not very numerous, circular groups, scattered over the sur- 
face of the body, but met with most frequently on the cheeks and arms. 
The ephemeral character, which is its only distinguishing feature, does not 
justify us in regarding strophulus volaticus as a distinct variety. 

The two remaining varieties, strophulus albidus, or white gum, and stroph- 
ulus eandidus, are both characterized by whitish instead of red papules. 



LICHEN. 93? 

In the former, the papules are white, minute in size, and surrounded eaeh 
by an areola of a taint red color; they appear usually on the fiice, nerk, 
and breast, and continue for some length of time. According to Tilbury 
Fox, the terra strophulus is a misnomer as applied to this form, which he 
regards as a sebaceous disease. In strophulus candidus, the papules are 
much larger, broader, more hard and tense, an«l are unaccompanied by 
any redness. They last usually about a week. This eruption is most com- 
mon during dentition. 

Diagnosis. — There is no difficulty in distinguishing strophulus, as it is 
the only papular eruption to which infiint:? are subject. The absence of 
general symptoms and the extreme mildness of the disease are amongst its 
chief characters. It must be remembered that we only regard such pap- 
ular eruptions as are unassociated with exudation or eczematous patches 
elsewhere on the surface as true instances of strophulus, since papules in 
all respect.s resembling those of this disease are to be frequently observed 
in cases of eczema papulosum. 

Prognosis. — The eruption is never attended with any danger. If severe 
symptoms happen to coincide with it, they must depend on some other causes 
than the cutaneous affection. 

Treatment. — As a general rule, strophulus needs no treatment what- 
ever. In infants within the month, the irritation of the skin, if it be 
such as to disturb the comfort of the child, may be allayed by the use of 
the tepid bath, and by dusting with some mild powder, or by anointing 
with cold cream, glycerin and cold cream, simple cerate, or cocoa-butter. 
When any marked disturbance of the digestive apparatus is present, this 
should be attended to by the administration of mild laxatives, and of 
tonics, with some preparation of iron, as the tartrate or superphosphate. 

In older children, in whom the disease appears to be associated with 
dentition, the local means spoken of above may be employed, while, at 
the same time, the gums should be lanced, if necessary, and any gastro- 
intestinal disturbance removed by appropriate treatment. 



ARTICLE II. 

LICHEN. 

In children the lichenoid eruption takes so constantly the form of stroph- 
ulus, that we deem it unnecegsary to give a separate description of the 
former disease, with the exception of one of its varieties, the lichen tropi- 
cus. No doubt cases of lichen simplex do occasionally occur in children 
as they approach the age of adfdescence, but since the disease resembles 
so closely in its character?, and requires the pame treatment as strophulus, 
what has been said in regard to that disease will |)crfectly well apply also 
to lichen. Of lichen agrius, a not uncommon and severe form of the 
er'iiiT'..ii in mlnlr, we have never seen an example in a child. 



938 LICHEN. 

Lichen Tkopicus, or Prickly Heat. — This is a form of lichen sim- 
plex which occurs principally in hot climates, and during the hot summer 
season of the more southern temperate climates. It is a very common 
eruption at all ages of childhood, from early infancy upwards, in this city, 
and in most of our Middle and Southern States, and is commonly known 
by the name of prickly heat. Tilbury Fox {op. ciL, p. 484) regards it as 
essentially a congestion or inflammatory affection of the perspiratory fol- 
licles, and differing therefore entirely from true lichen. 

The chief cause of lichen tropicus is apparently the action upon the 
cutaneous surface of a high temperature, aided, no doubt, by the disturb- 
ances of the digestive function so apt to occur under the influence of that 
condition of the atmosphere. Very warm clothing, and particularly the 
presence upon the skin of thick rough flannels, is apt to develop the erup- 
tion. 

Symptoms. — The eruption of prickly heat consists of numerous small 
papules, few of them being larger than a pin's head, scattered more or less 
thickly over the affected surface. The pimples are of a red color, which is 
more or less bright in tint, according to the extent and intensity of the 
eruption. The skin between the papules retains its natural appearance 
when the eruption is but slight or moderate; but when this is copious 
and severe, it assumes a faint reddish appearance, owing no doubt to the 
activity of the circulation in the part. 

The eruption is most abundant on the parts covered by the dress, or 
rubbed by the edges of the dress, particularly about the neck, upper part 
of the chest, and on the arms and legs. We have sometimes seen it cov- 
ering the greater part of the body. It is always attended with more or 
less itching, burning, and pricking, which, in older children, causes much 
fretfulness and scratching, and, in those who are younger, restlessness, wor- 
rying, and more or less disturbance of the sleep. The disorder usually 
remains stationary for several days, and then disappears gradually without 
desquamation or other change in the skin ; or, it subsides and increases, or 
disappears and returns, with the rising and falling of the temperature, or 
without any very evident cause, until at last it ceases, not to appear again. 
When the eruption lasts many days, it is almost always accompanied by a 
slight scaly desquamation of the tops of the pimples. 

The diagnosis of this form of eruption is never difficult. Its occurrence 
during hot weather, the character of the papules, their minuteness and 
abundance, and the entire absence of constitutional disturbance, will 
always render it easy of recognition. 

Treatment. — Lichen tropicus is usually regarded as a salutary erup- 
tion, and as therefore not to be interfered with by treatment likely to repel 
it. In fact, it never needs any treatment, except when very abundant, and 
when it annoys the child by the heat and itching it occasions. Under 
these circumstances, the skin should be dusted with rye-meal, or anointed 
two or three times a day with some mild ointment, as, for instance, one 
consisting of glycerin and cold cream or lard, or the benzoated zinc oint- 
ment; or, the child may be bathed once or twice a day in warm water 
containing bran, slippery-elm, or some other mucilaginous substance. 



PRURIGO. 039 



ARTICLE III. 



riuiuGO. 



Pefixitiox; Frf.qx'ency. — Prurigo is charaeterizod by an eruption, 
more or le;?s extensive, of isolated papules, which, larger than those of 
strophulus, unattended with any change in the color of the skin, and de- 
veloped usually on the extensor surfaces of the limbs, give rise to the most 
violent and distressing itching, a symptom which constitutes one of the 
most marked features of the disease. Wilson includes it among the ner- 
vous affections of the skin, and attributes it usually to nervous debility, 
with an impaired state of the nutrition and innervation of the skin. 

Prurigo is a rare disease in this city amongst the children of tiie middle 
and upper classes, since we have seldom met with it. In Europe, it is de- 
scribed as occurring in the children of the poor, though it is much less 
common than the eruptive diseases already treated of. Doubtless it occurs 
in this country also, but with the exception of a case reported by Wiggles- 
worth, of Boston (Avier. Jour, of Syph. and Derm., vol. iv, 1873, p. 21), 
we have not found any original account of it in the works of American 
writers. Duhring (op. cit., p. 252) states that the disease is extremely rare 
and almost unknown in the United States. 

Causes. — The only well-ascertained causes of the disease are the un- 
favorable hygienic conditions which exist amongst the destitute classes of 
society, — damp and ill-ventilated dwellings, unwholesome food, especially 
the use of salted meat^ and fish, and want of cleanliness as to person and 
clothes. 

Symptoms. — The papules of prurigo are small, but slightly prominent, 
and attended with moderate itching, constituting the pruritjo ?«j7m; or 
they are larger, more projecting, and attended with the m(K«*t violent pru- 
ritus, forming the prurigo formimns. The papules are usually of the color 
of the skin, except when they have been torn by the nails, and are gener- 
ally seated upon the outer surfaces of the limbs, and the upper part of the 
trunk. 

When the itching is severe, the tearing of the papules by the nails causes 
the escape of a small drop of blood from the to|>s of many of them. The 
hlofxl dries and forms so many .'•mall black crusts crowning the summitfl 
of the papules, a peculiarity which constitutes one of the most di.^tinctive 
features of the disease. The papules terminate by absorption or by a slight 
desquamation. After the disease has lasted some time, the skin acr|uire8, 
partiv from the constant and violent scratching, a peculiar thickened and 
harsh character, which \a most marked on the lower extremities. 

The duration of the eruption is very uncertain. In acute ca-es, when 
properly treated, it may end in a few weeks, though it often, and indeed 
more generally, la-sts for several months or years, or even through life. 

DiArjxosis. — The only di-^jases with which prurigo is likely to be con- 
founded are strophulus or lichen. It may be distinguished, however, gen- 



940 SQUAMA. 

erally with ease, by the facts that the papules of prurigo are larger, less 
numerous, and more extended, than those of strophulus or lichen ; that in 
the latter diseases the papules are never crowned by the small black crusts 
of prurigo, and they are never attended with the same violent itching as 
the former. 

From pruritus, it is to be distinguished by the absence in the former af- 
fection of papules, as well as of thickening and roughness of the skin. 
The regions affected in pruritus are also quite different from those most 
frequently involved in prurigo. 

Prognosis. — Prurigo is never perhaps a dangerous disease, though usu- 
ally a very troublesome one from the severe irritation which attends it, 
from its not unfrequently obstinate resistance to treatment, and its disposi- 
tion to relapse. According to Duhring, it is perhaps curable in children, 
but scarcely so when it has lasted until adult life. 

Treatment. — The internal treatment of prurigo in children should con- 
sist in the use of sulphur, given alone or in combination with magnesia, of 
demulcent drinks, of mild laxatives when there is constipation, and of such 
remedies as may be rendered necessary by any disordered state of the di- 
gestive function. The diet must be carefully regulated. It ought to be 
nourishing and sustaining, but at the same time light and easy of diges- 
tion. In obstinate cases, recourse must be had to the administration of 
arsenic, cod-liver oil, iron, and other powerful nutrient and alterative 
remedies. 

In addition to the internal treatment, simple warm-water baths, or 
emollient baths of flaxseed, bran, slippery-elm, or marsh-mallow, should be 
made use of in the early stage of the disorder. At a later period, alkaline 
baths, containing from three to eight ounces of carbonate of potash to each 
bath, according to the age, are recommended by Cazenave and Schedel. 
To allay the cutaneous irritation, mild ointments are often found useful. 
Billard employed with success, in a child six months old, inunctions with 
the oil of sweet almonds. Soaps or lotions, containing juniper tar or car- 
bolic acid, are excellent anti-pruriginous applications ; and relief will fre- 
quently be obtained from the application of a dilute solution of chlorin- 
ated soda. When the case is obstinate, resisting emollient and alkaline 
baths, sulphurous baths must be made use of. 



CHAPTER YI. 



SQUAM-E. 



The various forms of scaly disease, psoriasis, pityriasis, and ichthyosis, 
are so much more rare in children, and therefore so much less important 
practically, than the various eruptions we have thus far considered, that 
we deem it unnecessary, in a work limited in extent like this, to attempt 
a detailed account of them. We shall make merely a few observations on 



TREATMENT. 041 

each, referring the reader, should he desire further information, to the 
special treatises upon diseases of the skin. 

Psoriasis is, in our experience, a very rare disease in chihhcu, though 
we have met with a few cases of it. It is met with in two forms, the 
psorians diffusa and guttata, of which the former is said to uc the more 
frequent. 

Pi^oriasis diffum appears in the form of patches of rather large, but very- 
variable size, of irrcgular shajx^, and covered with thin scales of dried epi- 
dermis, which are constantly falling off and being renewed. When the 
scjiles are removed, the surface of the eruptive patch is seen to be of a dull 
red color, somewhat rough, and raised above the surrounding skin. In 
severe cases, as the disease occasionally occurs in young children, the skin 
presents numerous chaps and fissures, and is often excoriated more or less 
by the dress, or by the neighboring surfaces. From the excoriations is 
sometimes poured out an unhealthy secretion, which hardens and forms 
scabs. 

Psoriasis guttata appears in small, reddish, and rounded elevations, more 
elevated at the centre than the circumference, and of different sizes ; from 
that of the head of a pin, as mentioned by Billard, to that of a large pea, 
as seen by ourselves, and which become covered very soon after their ap- 
pearance with fine, minute and whitish scales. 

A third variety, psoriasis inveterata, a severe, obstinate, and inveterate 
disease, as met with in adults, is very rare, if not unknown, in cliihh'cn. 

Treatment. — In recent cases, psoriasis is to be treated with simple 
warm-water or emollient baths, and with mild liniments or ointments, such 
as oil of sweet almonds, glycerin alone, or glycerin mixed with cold cream 
or simple cerate. In more chronic cases, the local treatment is the only 
one which promises any certain success. The particular mode of local 
treatment which we have found most successful is that recommended by 
Hebra, a short account of which will be found in our remarks on the treat- 
ment of chronic eczema. 

The carbolic acid soap, dilute citrine ointment, or weak solutions of 
caustic potash when there is much infiltration of the skin, are all service- 
able applications in the chronic form of the disease. 

In all cases the digestive function must be carefully attended to, any 
disorder that it may present being removed as rapidly and effectually as 
possible by the proper remedies. 

In cases where the eruption persists despite the use of local applications 
and attention to the digestive functions, the child should Ik* placed upon 
the use of the ferro-arsenical mixture. 

Pityriasis is a slight scaly disease, which may attack the head only, or 
extend to other parts of the bo<ly. In children, however, it is generally 
confined to the scalp, and may l)c recognized by the existence on the part 
of innumerable small, thin, whiti>*h, furfuracoous wales, which form a thin 
or thicker covering for the scalp, in prop<jrtion to the amount of care Ikj- 
stowed on the cleansing of the head. The scales of epidermis are easily 
rubbed off, and the surface beneath is rarely found to present even the 
slightest inflammation. 



942 PARASITIC SKIN DISEASES. 

It is a disorder of minor importance, and seldom requires other treatment 
than some mild lotion or ointment, and strict cleanliness. When, however, 
it persists, the child should be placed upon the use of the ferro-arsenical 
mixture internally, and applications of dilute citrine ointment should be 
made to the patches of eruption. 

Ichthyosis is an eruptive disease in which there appears on various 
parts, and usually over the larger portion, of the skin, epidermic patches 
or squamae, that are hard and dry, and of more or less considerable size. 
The patches are generally of a dirty gray or earthy color ; they exfoliate, 
and leave the skin beneath more or less thickened and roughened, Ifut 
never inflamed. The disease is unattended with either heat, pain, or itch- 
ing. It is ordinarily congenital, and is extremely obstinate, lasting many 
years or even persisting during life. 

Billard recommends, however, in the ichthyosis of new-born children the 
use of warm and emollient baths, frictions, with oil of sweet almonds or 
olive-oil, acidulated drinks, and perfect cleanliness. 

In older children, baths, either simple or medicated, should be freely 
used in order to assist in removing, by maceration, the thickened layers of 
epidermis. Vapor baths are especially recommended by Duhring. Sub- 
sequently the removal of the hypertrophied epiderm should be still further 
secured by inunctions with strongly alkaline soaps or lotions, then mild 
alterative applications should be made to the exposed new skin beneath. 



I 



CHAPTER VIL 

DISEASES OF THE SKIN NOT CLASSIFIED AMONGST THE PRECEDING. 

SECTION I. 

PARASITIC SKIN DISEASES. 

General Remarks. — The diseases now regarded by many authori- 
ties as due to the presence of a vegetable parasite upon the skin are as 
follows : 

1. Tinea Favopa or Favus, Parasite : Achorion Schoenleinii. 

/- Tinea Tonsurans (Kingvvorm of scalp), 1 

2. Tinea Trico-J rf,-^^^ Circinaia (Ringworm of body), IParasite: Tricophyton. 

phytina, ( rpj^g^ Sycosis (Ringworm of beard), J 

3. Tinea Versicolor (Chloasma, Wilson), . . . Parasite: Microsporon Furfur. 

4. Tinea Decalvans (Alopecia Areata), .... *« Microsporon Audouini. 

There are several questions, however, in regard to these affections upon 
which doubts still exist, and which are of so much importance as to de- 
mand a brief examination. 



GENERAL REMARKS. 943 

In the first place, it can scarcely be douhte<i by any one familiar witli 
the use of the microscope, and who has taken the trouble to examine the 
subject, that parasitic fungi are found with remarkable constancy in the 
eruptions of these diseases. The opinion advanced by Wilson (^Br. and 
For. ^Jed.-Ch{r. iiVr., 1864, and DL^case^ of the Skin, 7th Amer. «>d., p. 614), 
that the structures found in these cases, are due to a peculiar "granular" 
degeneration of the normal elements of the part, owing to whiili they lose 
their power of developing into healthy epithelial structures, but retain their 
power of proliferation, appears to us opposed to all sound reason and accu- 
rate observation. 

In addition, however, to the evidence furnished by the chemical and 
microscopical examination of the growths in question, their fungous na- 
ture is shown by the facts that they can be cultivated after removal from 
the body, and that the diseases with which they are associated are conta- 
gious and can be commuuicateti by inoculation to healthy j^ersons, or even 
to some of the lower animals. 

hi searching for these growths, the scrapings from the surface of the 
diseiised spot, or the hairs which traverse it, may be taken for examina- 
tion ; but before subjecting them to microscopic study, they should be 
treated with dilute acetic acid to render them more translucent, and sub- 
sequently with a little sulphuric ether to remove the fatty granules which 
often obscure the fungus. 

The structures which the fungi affect are the hairs with their follicles, 
and the epidermis. 

The special alterations which the hairs undergo will be detailed under 
the head of the ditlerent diseases ; the fungus gains entrance to the folli- 
cle, penetrates the bulb of the hair, insinuates itself between its longi- 
tudinal fibres, thus splitting it up and rendering it brittle. In the epi- 
dermis the fungus is said at first usually to ap|>ear beneath the superficial 
layer, until, by its development, it causes such irritation as leads to the 
exfoliation of this layer, when it reaches the surface and then multiplies 
rapidly. 

The objection which has been based upon this fact, that the growth can- 
not be a parasitic one, does not seem to us of much force, since it is ea.**y 
to account for the introduction of such extremely minute biKlies as the 
spores of these fungi beneath the superficial layer of tho cuticle. 

Admitting then the presence of these parasitic growths, a more interest- 
ing question arises in regard to the relation which exists between them and 
the diseases with which they are associated ; whether, that is, they are es- 
sential to, and actually the causes of the respective di.<(eases, or are merely 
accidental, and are present only l>ecau»c they find a suitable nidus for de- 
velopment in the diseased skin. Opinions are at variance upon this (pies- 
tion, but there are at least two considerations which render it probable 
that the fungi are essential rather than accidental pnKluctionj*. The fin»t 
of these is, that they are prcj*ent in the early stages of the diM.'ase, U-fore 
any considerable inflammatory change has occurred, and that in pnijnirtion 
as suppuration ensues they diminish in abundance. And, secondly, that, 



944 PARASITIC SKIN DISEASES. 



as already stated, they are capable of transmission to perfectly healthy 
persons by inoculation. 

There can, however, be no doubt that the development of the fungus, 
under ordinary circumstances, is greatly favored by the constitutional con- 
dition of the patient and the state of the cutaneous surface. Thus it is 
especially in children of a delicate or strumous constitution, that these 
various diseases are most frequently met with ; and when, in addition, 
personal filthiness with inattention to properly combing and cleansing the 
hair, and changing the clothing, are combined, the spores find the most 
favorable conditions possible for their rapid development. 

There remains the further question, upon which authorities are still di- 
vided, whether there are various fungi concerned in the production of these 
diseases, or whether the apparently different species are merely different 
stages of a single fungus. For the sake of greater ease of reference and 
comparison, we will here give a brief description of their characteristic 
appearances. 

Fungus of Tinea Favosa. — In the earliest stage of development of the 
favus crust, it is still covered by the superficial layer of epidermis ; but 
later, when this is ruptured, it presents an envelope of a sulphur-yellow 
color, which on microscopic examination shows a homogeneous or finely 
granular substance. The interior, of a pale white color, is the true 
favus matter, and consists of the sporules, thalli, and mycelia of a fungus 
named the achorion Schoenleinii, in honor of Schoenlein, who first fully de- 
scribed it. 

The sporules are of a rounded, or more frequently of an oval form, and 
have well-marked edges, and a homogeneous and slightly opalescent in- 
terior. Their average diameter is about uoV^th of an inch. Many of 
these sporules are seen to be grouped together, while some are more 
elongated and present a contraction in the middle; others are nearly 
triangular in form, with rounded angles ; others, yet more elongated, are 
marked with several contortions. Some sporules, completely formed, seem 
to have a double envelopment membrane, and others present in their in- 
teriors something like a nucleus. 

There are also present numerous diaphragmated tubes, formed by the 
development and confluence of the sporules, which are either simple or 
present ramifying branches. These tubes vary in diameter from loVoth 
to Tshoth of an inch, and are either empty or have granular contents. 
Amongst the sporules and mycelia, especially towards the circumference 
of the cups, may be seen a considerable number of molecular granules, 
which are probably imperfectly developed sporules. 

Fungus of Tinea Tricophytina. — The next parasite, the tricophyton, is that 
which produces tinea tonsurans, tinea circinata, and tinea sycosis. 

The microscopic characteristics of this parasite, as first described by 
Malrasten, in 1845, and since confirmed by numerous observers, are very 
numerous rounded or oval sporules, about ToVuth of an inch in diameter, 
which. are isolated or united together into chains, and a comparatively 
small number of mycelial threads. 

Again, the parasite, which by many observers is believed to cause tinea 






FUNGUS OF FAVUS. 045 

versicolor, is the micrOsporo7i furfur, discovered by Eichstiidt, iu 1846. 
This fuugus presents numerous rounded spores, and long tubes. The 
spores are about 3^0*0 o^^^ '"^*^^ '" diameter, and are tVeiiuently collected to- 
gether in large clusters, like bunches of grapes (Anderson). Some of the 
tubes observed are simple, and others jointed. 

In regard to the parasitic nature of alopecia areata, there is great doubt, 
and even so warm a supporter of the fungous origin of the other diseases 
we have mentioned as Dr. Anderson, does not allow it. 

Numerous observations have been made which go to show the exist- 
ence of a very wide range of variation as regards form in these fungi ; and 
have led some observers to assert not only the identity of the^e particular 
forms, but indeed to refer all varieties of epiphytic fungi to some one cen- 
tral type. 

The evidence upon which this view rests, mainly drawn from the results 
obtained from germination of the various fungi, and from the study of 
their transitional forms, cannot at present be considered conclusive ; and 
further investigation of the question is demanded. 

It is, however, thought by some high authorities, that no doubt can be 
entertained in regard to the identity at least of the parasites which produce 
the various forms of tinea, including the achorion of favus, the microsporon 
furfur of tinea versicolor, and the tricophytou of the various varieties of 
ringworm. The most complete exposition of the arguments upon which 
this view is based, will be found in Dr. Tilbury Fox's admirable treatise 
on skin diseases of parasitic origin (London, 18G3;. 

On the other hand, some eminent dtermatologists believe that the fungi 
which produce these diseases, are essentially distinct. The arguments upon 
which they base this opinion may be briefly expressed as follows, in the 
language of Dr. Anderson (loc. cit, p. 170). 

That in all cases of successful inoculation with the achorion, tricophytou, 
and microsporon furfur, the same parasitic disease has been j)roduced as 
that from which the parasite was taken. That of the innumerable cases 
occurring in the human subject, illustrative of the contagious nature of 
favus, tinea tonsurans, and tinea versicolor, there is no authentic case in 
which one of these diseases gave rise to one of the others. 

That the difference in the appearance of the eruptions, when fully de- 
veloped, is so very striking as to lead to the belief that they are produced 
by separate parasites. 

That there is no authentic record of the transition of one of these dis- 
eases into one of the others. 

That the raicrosa>pic differences between the throf ^M-.r; .r. ir, many. 
cases 8ufl[icient to base a correct diagnosis upon. 

That of the numerous instances* on record of the traii.-ini.%-»i(»n of tinea 
favosa, and tinea tricophytina, from the lower animals by contagion or 
inoculation, favus has always given rise to favus, and tinea tricophytina to 
tinea tricophytina. 

We regard then the parasitic nature of these affections as undoubted, 
but more extended observation is Deoeasary before the relations of their 
respective fungi can be determined. 

60 



946 TINEA FAVOSA OR FAVUS. 

ARTICLE I. 

TINEA FAVOSA OR FAVUS. 

Favus is a parasitic disease of the scalp, long confounded by different 
writers with other and very dissimilar affections of that part. In conse- 
quence of this confusion it has received a great variety of names, of which 
the most generally known are porrigo and tinea. In adopting the above 
title, we follow the example of Erasmus Wilson and other recent author- 
ities, amongst the English, and of MM. Rilliet and Barthez, Gibert and 
Rayer, amongst the French. 

Definition ; Synonyms ; Varieties ; Frequency. — Favus is a spe- 
cific contagious eruption of the scalp, characterized by inflammation of 
the hair-follicles dependent upon the presence of a peculiar fungus, the 
achorion Schoenleinii. It is distinguished at first by small yellow pustules, 
countersunk in the skin ; these are soon converted into yellow cuplike 
crusts, which adhere often for a very long period. It usually causes per- 
manent loss of hair at the affected part. 

The disease is described by most of the former English writers under 
the title of porrigo, but as several other eruptions have been included 
under the same name, we think it best to follow the example of Mr. E. 
Wilson, and call it favus. By MM. Biett and Cazenave it is designated, 
after Willan, porrigo favosa and porrigo scutulata. MM. Rayer and 
Gibert, as above mentioned, give it the name of favus. 

There are two varieties of favus, the favus dispersus, the porrigo favosa 
of most writers, and the favus confertus, the porrigo scutulata of many 
observers. 

The disease is much less frequent than eczema of the scalp, but is 
nevertheless constantly met with amongst the crowded populations of 
Europe. In this country it is more rare, and amongst the middle and 
upper classes, at least of this city, is almost unknown, since we have 
never met with a case of it in our own private practice, though we have 
occasionally seen it in the hospitals here. 

Causes. — The only well-ascertained exciting cause of favus is generally 
thought to be contagion, a quality of the disease acknowledged by most 
observers, though denied by Mr. E. Wilson, who considers its cause a 
debility of nutritive vitality, allied with struma. It may be propagated 
,by direct contact of the diseased with a healthy skin, or by means of 
combs, brushes, or other articles of the toilet ; and it is also probable that 
the spores may be carried by the atmosphere so as to communicate it by 
infection. It has been frequently propagated by direct inoculation, — by 
Remak, Bennett, Hebra, Bazin, Gruby, Kobner, etc. 

Favus is also said to be met with in the lower animals, and especially 
amongst mice and cats ; and cases are on record which render it highly 
probable that it may be communicated from them to the human subject. 

It occurs at all seasons, attacks either sex indifferently, and is met with 



I 



SYMPTOMS. 947 

at all ages, but is especially frequent in. children and young people, ami, 
indeed, when met with in adult-j, is usually found to have comnienct^l in 
early life, and to have j^rjiistetl for years. Certain conditions act as pre- 
disposing catises in its production, and may alone, perhaps, give rise to its 
development. These conditions are unhealthy hygienic intivences, as 
unwholesome and insufficient food, poverty, tilth, and the living in low, 
damp, and ill-ventilated dwellings. It is met with most frequently in 
persons of feeble, lymphatic, and especially in those of scrofulous consti- 
tution, though, be it remarked, it occui*s also in persons of strong and 
vigorous health. 

Among those who believe in its truly parasitic nature, there are some, 
as Devergie, who believe that it may be spontaneously generated, the 
parasite originating in the body of the affected person. One of the facts 
upon which the theory is based is the asserted occasional cure of the dis- 
ease by internal remedies, but we believe that these can only relieve it by 
fortifying the system, and so removing the conditions which favored the 
development of the parasite. 

Symptoms. — Favis Disi»ersvs, or PoRRUiO Favosa. — This variety 
begins with very small pustules of a peculiar straw-yellow color, which 
exhibit from the first the special character of not being raised at all above 
the level of the skin. Directly after their formation, the yellowish matter 
which they contain begins to concrete, and there can be i)erccived tVom 
this early period a central depression in the crusts, which becomes more 
marked as these augment in size, so that at the end of five or six days it 
is perfectly evident. Each pustule, and of course each crust is, as a gen- 
eral rule, traversed by a hair. The favous crust is a very remarkable 
feature of the disease, and is in itself a pathognomonic symptom. As it 
increases in size, which it does gradually until it reaches in some instances 
a diameter of half an inch, the central depression above spoken of he- 
comes more and more distinct, and the crust a.ssumes, from this circum- 
stance, the shape of a cup with an inverted edge. Their structure is made 
up of a series of concentric layers, or layers or rings, compactly arranged 
one upon the other. This cuplike form with the concentric arrangement 
of lavers, the peculiar straw-yellow color, and the fact that each crust is 
usually pierced by a hair, are the distingui.>*hing characters of the di.«ease. 

The pustules are usually i.solated at first, though they may be arranged 
in groups of irregular size. When numerous, the cruj*ts, by their gradual 
enlargement, touch at their edges, and blend into larger or smaller patches 
of irregular shajx;, but still presenting many little depressions corrcsjwnd- 
ing to the first-formed pustules. In rare cases, the diK-ase is so extensive 
as to form a kind of mask covering the whole scalp. 

When the di.«ease is not interfered with by treatment, the cruets rf main 
adherent for a long time, — for months or even years ; they become al.-o 
paler in color than they were at first, and so dry and pulverulent, as to 
break very readily when rubbed or touched. They U'come, moreover, 
thicker and more ma-ssive, and lose their first regular cuplike form, from 
the disappearance of their depressions, and from the irregular and uneven 
shape given to their edges and surfaces, by the breaking which they 



948 TINEA FAVOSA OR FAVUS. 

undergo. When the case runs on in this way, the head exhales a most 
unpleasant odor, which has been compared to that of mice or the urine of 
a cat ; McCall Anderson has, however, noticed a very similar odor in cases 
of eczema irapetiginoides of the scalp. In some instances, where the 
disease is grossly neglected amongst the very poor, pediculi form in abun- 
dance amidst the crusts, and add to the disgusting appearance of the dis- 
order. 

When the crusts have been removed by any means, the surface of the 
Bcalp is seen to be red, moist, and to present slight erosions or even ulcer- 
ations. The crusts are reproduced only by the eruption of new pustules. 

An invariable and unfortunate sequel to the favous disease is a more or 
less extensive loss of the hair. The hairs become loose from a very early 
period of the disease, and can be pulled out with great ease. As the case 
goes on they fall out, and the scalp is left smooth, shining, uneven, and 
deprived of hair. On these spots the hair seldom grows again, and if it 
does, it comes out thin, woolly, and with every appearance of weakness 
and unhealthfulness. 

Though the usual and favorite seat of favus is the scalp, it is met with 
occasionally on the forehead, temples, chin, and eyebrows, and, in still rarer 
instances, on the shoulders, elbows, forearms, on the upper and outer parts 
of the legs and thighs, on the scrotum, and even on the nails. The nails 
are also liable to be invaded, probably in consequence of the parasite 
gaining entrance during the act of scratching. The affected nails become 
thickened, yellowish and opaque, and brittle. Even in such cases, how- 
ever, it has frequently existed first on the scalp, and extended thence to 
the other parts, though it may sometimes begin upon the trunk or limbs 
in consequence of a direct application to them of the contagious element. 

Favus Confertus, or Porrigo Scutulata. — In this variety of favus 
the pustules are arranged so as to form circles or rings upon the forehead 
or scalp, instead of being dispersed irregularly over the scalp, as in the 
preceding variety. The disease begins with red, circular patches, attended 
with a good deal of itching, upon which, after a short time, appear small 
yellow pustules, that seem to be sunken in the skin. The pustules are 
more numerous on the circumference than at the centre of the red patch 
or disk ; or the latter increases in size by the extension of the disease to 
the follicles just beyond its outer edge. The pustules are exactly like 
those of favus dispersus, except that their yellow color is of a lighter tint. 
They desiccate very rapidly, and form crusts which are very thin at first, 
never very thick, and of an irregular shape. 

When the disks are very numerous, either originally, or by propagation 
of the disease from part to part, they meet at their borders, blend together, 
and give to the scalp the appearance of an extensive and irregular crust, 
presenting at its circumference curved lines, marking the segments of circles 
of which the whole is composed. The crust has sometimes covered the 
whole scalp, excepting merely a small border at its circumference, where 
may still exist some scanty remains of the hair. 

When the crusts are removed, the surface beneath is found to be red 
and tumid, according to Wilson, and to present numerous yellow points. 



I 



DIAGNOSIS. 049 

Cazenave and Schedel state that when the crusts fall, they leave exposed 
a large, imeveu, furturaeeous patch, up<Mi which now faviis piistuk\s do not 
appear often for a long time. The hair is in great measure destroyed over 
the diseased surfaces, though not so completely, it is said, as iu the other 
variety. 

Favus is not, in either variety, attended with constitutional symptoms. 
The only marked local symptom complained of is the itching, which is 
always greatly aggravated by want of cleanliness. 

Nature of Favvs. — We have already, in our general remarks intro- 
ductory to this class of skin diseases, given the arguments which prove 
their parasitic nature. 

Mr. E. Wilson, alone among dermatologists of note, persists in regarding 
favus and the others, as due to mere alterations in the nutrition of the 
skin dependent upon constitutional nutritive debility; and he refers the 
characteristic fungous elements revealed by microscopic examination, 
merely to a peculiar granular degeneration of the epithelial elements. 

We refer the reader, for a more full discussion of this question, to the 
works already quoted, merely adding here that, in our opinion, the results 
of microscopic examination, the results of inoculation of the parasite iu 
man, as well as in the lower animals and plants, the undoubtedly contagious 
nature of the disease, and finally the astonishing and never-failing success 
of the local treatment when properly carried out, conclusively show its 
parasitic nature. The reader is also referred to the remarks introductory 
to this chapter for a full description of the parasite, the achorion Sch«^n- 
leinii, which is the essential cause of favus; as well as for the differences 
which distinguish it from the parasites which are found in the various forms 
of tinea. 

Diagnosis. — The diagnosis of favus rarely presents any difficulties. 
The peculiar pustules which exist at first — small, yellow, on a level with 
or below the surface of the scalp, and the crusts which so soon follow these, 
saflTron-yellow in color, dry, and cup-shaped, will mark a case of favus 
dis|iersus from every other disease. In favus confertus the same characters 
exist, but the crusts and pustules are arranged on circular erythematous 
disks, instead of being isolated or dispersed as in favus dispersus. 

From impetigo of the scalp, which is the only disease with which it is 
at all probable that it would be confounded, it may readily be distinguished 
by an examination of the primary characters of the two disorders. This 
primary- character can always be found by searching at the outer edgej* of 
the diseased surface. In favus the pustule is small, dopro-ssod, and contains 
very little fluid, while in impetigo it is large, globular and projerting. 
The crusts are very different: in the former dry, as though dusted with 
sulphur, cup-shaped, depressed, and usually traversed by a hair ; in the 
latter, rugous, irregular in shape, not cupped, resting above the skin, and 
generally somewhat moist and soft. The peculiar odor which is pre.'^ent 
in cases of favus may be of a«vistance, although a very similar odor has 
been observed in cases of different characters. The microscopic examina- 
tion of the hair or crusts in favus also shows the preseDce of the achorion 



950 



TINEA FAVOSA OR FAVUS. 



Schoenleinii, wliich is never met with in impetigo. Lastly, the alopecia 
which so constantly results from favus, does not occur in impetigo. 

PrcXtXOSIS. — Favus is a serious disease because of its usually long du- 
ration, the difficulty often experienced in effecting its cure, and because of 
the loss of hair which it occasions. 

Treatment. — The treatment of favus should be both general and local, 
for though some writers, and particularly Cazenave and Scbedel, state 
that it must be altogether external, and that in spite of numerous trials 
they do not feel authorized to propose any internal means {Malad. de la 
Feau, 4eme ed., p. 826) ; others, as Wilson, Bennett, and Neligan, recom- 
mend constitutional remedies as of very great importance in assisting the 
cure. 

The general treatment must be such as may seem called for by the state 
of health of the individual patient. When, as so often happens, the dis- 
ease occurs in a scrofulous person, cod-liver oil, iodide of potassium, nour- 
ishing food, air, and exercise, are of the utmost importance. When the 
health of the patient is feeble and broken from the want of wholesome 
and abundant food, from insufficient clothing, or from residence in a viti- 
ated, close, and confined air, the removal of these conditions, which un- 
doubtedly act as predisposing causes in the production of the disease, 
cannot but aid in its cure. Dr. Neligan {Dublin Quart. Journ. of Med. 
Sci., vol. vi, p. 56) recommends very highly the use of the iodide of arsenic 
as a constitutional remedy. It must be given in doses carefully gradu- 
ated to the age of the patient (one-eighth of a grain being the proper 
dose for an adult), and should any symptoms of its irritative action ensue, 
its use must be immediately 'suspended for a few days, and a purgative be 
administered. 

The local treatment of favus is undoubtedly that upon which we must 
chiefly rely, since the essential element in the treatment must always be 
the destruction of the parasite. 

The mere application of remedies adapted for this purpose, called para- 
siticides, is, however, rarely of itself sufficient, since they cannot penetrate 
to the hair- follicles, and it is, therefore, directed by most authors of expe- 
rience in the treatment of this disease, that the hairs must be removed 
from the affected parts before the application can be efficiently and suc- 
cessfully made. Before doing this the crusts must be removed. Some 
recommend for this purpose poultices, but these are condemned by Wil- 
son, as clumsy, and by Lebert as causing the extension of the disease by 
the softened sporules which spread to the surrounding surfaces and prop- 
agate the disorder. This objection does not, however, appear valid, and 
their use is countenanced by many good authorities. Wilson recommends 
their removal by means of a local vapor-bath, applied through the me- 
dium of a caoutchouc cap, or, if this is not at hand, by laying a piece of 
folded lint, wetted in a solution of subcarbonate of soda or potash, upon 
the head, and covering it with an oiled silk or gum-elastic cap, which 
should include the entire scalp. M. Lebert insists upon the necessity of 
removing the favi (not the pustular crusts which accompany the specific 
vegetable growth), in their dry state, by means of small spatulas, needles, 



TREATMENT. 951 

or some kiud of instrument. The epidermis is readily detached from 
around the favus, and this latter, which adheres but slightly to the skin, 
is then easily removed. M. Lebert states that this is so easily done, that 
be has been able to teach his ward -attendants to remove them without 
pain to the patients. Hebra uses applications of alcohol, whi<-li cause the 
crusts to shrink and thus lose their attachments, when they are readily 
removed. 

After the crusts have been gotten rid of, the scalp should ho well washed 
with soap and water in order to remove any favous sporules that may have 
escaped and become free, and the hair should then be cut short. Various 
applications are then recommended, before proceeding to epilation, as tend- 
ing to allay the irritability of the scalp and to render the hair less friable; 
among these are oil of cade (.Bazin), and almond-oil (Anderson), which 
may be applied for a few days before epilation is begun. There are vari- 
ous methods which have been adopted for the extraction, but the best is 
undoubtedly to employ a small pair of forceps with square ends, and fine 
but not sharp teeth, so as to enable the operator to catch the delicate and 
brittle hairs surely without breaking them. The hairs must be extracted 
singly, and so soon as a little space has been cleaned, the parasiticide rem- 
edy should be applied so as to secure its entrance to the follicle. A single 
epilation is frequently not sufficient, but it is easy to distinguish, by the 
appearance of the surface and the growing hairs, those parts where the 
disease has been eradicated. This process is at first somewhat tedious both 
to operator and patient, but by practice a degree of skill is acquired which 
enables the physician or trained nurse to remove the hair rapidly and with 
very little discomfort to the patient. 

So soon as a clean surface has been thus obtained, some application in- 
tended to destroy the vitality of the vegetable growth ought to be made 
use of. One of the best for this purpose is a solution of corrosive subli- 
mate, the strength of which, according to Lebert, ought to be, when em- 
ployed in lotion, from two to four grains to the ounce, and, when used as 
a fomentation, weaker. This is also McCall Anderson's favorite applica- 
tion. Dr. Bennett {Raukinrjs Hfdf-Yefirly AbMrnrt, No. xii, IS.")!), Am. 
ed., p. 73 j, employs, to fulfil this indication, cod-liver oil. The head is 
kept constantly smeared with the oil, and covered with an oiled silk cap. 
This application is, however, merely palliative, and, so soon as it is inter- 
mitted, the disease reappears. 

There are various other remedies that have been applied to the diseased 
scalp empirically, either to "rawlify the state of the skin," to "excite the 
disordered follicles to healthy action," or, lastly, to "destroy the vitality 
of the fungus, and, by altering the nature of the soil on which it flour- 
ished, to prevent its reproduction." Without attempting to define the 
mode in which any of these various substances may produce their effect, 
we deem it best to mention as succinctly as possible those which have the 
strongest testimony in their favor. 

Mr. E. Wilson, who it will be remembered docs not believe in its para- 
sitic nature, is less favorable to strong applications than he was formerly. 
Those he now prefers are the ceratum tiglii, containing from ten to thirty 



952 TINEA FAVOSA OR FAVUS. 

drops of the oil to the ounce ; the unguentum hydrargyri nitratis, diluted 
one-half; the unguentum hydrargyri nitrico-oxidi, diluted in similar pro- 
portion ; the compound sulphur ointment, and some others. 

Dr. Bennett's application of cod-liver oil has been referred to above. 
This, in connection with the constitutional treatment for scrofula, is said 
to have cured, on an average, in six weeks. 

MM. Cazenave and Schedel recommend alkaline and sulphurous appli- 
cations, and acidulated lotions. They speak very favorably of, and give 
much the highest place, amongst the substances to be used in friction, to 
the iodide of sulphur. This remedy was originally made use of by Biett, 
and employed by him with much success. Its efficacy is attested also by 
Lebert. It is used in the form of an ointment, consisting of from a scruple 
to half a drachm of the drug to an ounce of lard, which is to be applied 
morning and evening to the diseased surfaces by gentle friction. 

Applications of hyposulphite of soda, in proportion of 5j to f^j of 
water, or of sulphurous acid lotions, are highly recommended. Among 
the parasiticides most valued in France, are oil of cade and turpeth min- 
eral, which latter may be employed in the proportion of 5j to f ^j of glyce- 
rin of starch, which is perhaps the best excipient for the various parasiti- 
cides. 

Ointments and lotions containing carbolic acid have been much em- 
ployed of late, but apparently not with entire success. 

Dr. Fuller recommends the ablution of the head twice a day by means 
of soft soap, and the inunction of an application composed of equal parts 
of unguentum hydrargyri ammonio-chloridi, and unguentum picis liquidse. 
He states that a cure may usually be effected by this plan in from two to 
four weeks. 

When the disease affects other parts of the body, the treatment must be 
similar to that above recommended ; epilation is, however, unnecessary, and 
a cure is usually more promptly obtained. When the nails are invaded, 
they should be cut and scraped, and the parasiticide application should be 
rubbed into and beneath the free border of the nail. 

Under any plan of treatment, a complete cure is rarely obtained in less 
than from four to eighteen weeks ; the disease is extremely obstinate and 
there is a strong tendency to the redevelopment of the parasite after the 
cessation of the local treatment, until it be completely eradicated. By 
persevering in the plan above recommended, however, this can invariably 
be effected, and a perfect cure obtained, with the exception of patches of 
baldness, which but too frequently follow, from the destruction of the 
hair-follicles. 



I 



TINEA. 053 



ARTICLE II. 

TINEA. 

We have already, in our general remarks introductory to tliis chapter, 
stated our belief that the various forms of tinea or rinjxworm are con- 
tagious diseases, and due to the pre^jeuce of a peculiar fungus, the tri- 
cophyton. 

The ordinary varieties of tinea which are described, are tinea tonsu- 
rans, or ringworm of the scalp; tinea circinata, or ringworm of the gen- 
eral surface ; and tinea sycosis, or ringworm of the beard. With the lat- 
ter form, of course, we are not at present concerned, nor are its relations 
to the two other varieties indisputable, since opinions are still divided as 
to its contagious and parasitic nature. 

There is, however, abundant reason for believing the essential identity 
of tinea tonsurans and tinea circinata. In addition to the results of mi- 
croscopic examination, which reveals the presence of the same funirns in 
both, there is the strongest clinical testimony to the same effect. Thus it 
constantly happens that patches of the two varieties will be observed upon 
the same patient, and there are innumerable instances on record to prove 
that they give rise to each other. 

These diseases were formerly described by some authors under the gen- 
eric Dame of porrigo ; by others under that of herpes. Wilson, in his last 
edition, employs the term trichinosis to designate the group. 

Causes. — The peculiar parasite, the tricophyton, is the essential cause 
of the disease; and the mode of its propagation is chiefly by contagion. 
Mr. Wilson believes the cause of the disease to be imperfect nutrition ; 
but it is quite certain that the only way in which a scrofulous or debilitated 
constitution can influence the production of the disease, is by favoring the 
more ready growth of the parasite. In like manner, dirtiness of every 
kind may be said to be a predisposing cause. 

The influence of these is, however, trifling, and wi- have fn'tjucntly una 
with the disease among families living in easy or very aftluent circum- 
stances, the children of which were perfectly well lodged, well clothed, 
and well fed, and to whom every attention required by the nicest cleanli- 
ness was given. The means by which the affection is communicated are 
such as brushes, combs, caps, etc., or by the direct contact of the diseased 
surfaces. 

One of us has but lately had an opportunity of studying, on a large 
scale, these afl^ections and the mode of their transmission, at a large Chil- 
dren's Home in this city. There were a considerable number of children, 
about twenty in all, affected with the disease in a severe form ; by strict 
isolation, by the utmost care in preventing any use of their combs, 
brushes, cajw, or clothing, by the other children, by covering the entire 
scalp with an oiled-silk cap, whenever they minglc<l with their comrades, 
the disease was prevented from spreading. It was, however, frecjucntly 



954 TINEA. 

observed, that in the children who suffered with tinea tonsurans of the 
scalp, patches of tinea circiuata would appear either on the neck or face, 
or on some part which could be brought in contact with the affected sur- 
face ; and its highly contagious nature was unhesitatingly believed by all 
the attendants, who had indeed themselves furnished the strongest evidence 
possible of it, by each and all contracting the disease repeatedly from 
handling the children in dressing them, or in making applications to the 
affected parts. 

Age exercises a marked influence upon the production of these diseases, 
tinea tonsurans being confined to childhood and early youth, most com- 
monly occurring between the ages of three and twelve years ; though tinea 
circinata may be met with at any age. 

Tinea Tonsurans. — Symptoms. — The disease most frequently begins 
with little erythematous patches, which soon become covered with furfura- 
ceous scales, and which increase circumferentially while they heal in the 
centre, leaving the skin more or less furfuraceous. Occasionally there 
may be a crop of minute vesicles on the patch, which are soon followed 
by desquamation. When fully established, the disease appears in the 
form of furfuraceous patches of oval or circular shape, which are at first 
not more than |-th or Jth of an inch in size, but which increase gradually 
until they attain a diameter of one or two inches, and seldom more. The 
diseased surface is slightly thickened, elevated, of a grayish, bluish, or slate 
color, and covered with fine dry scales, which are very easily rubbed off, 
and are quickly renewed after being removed by any cause. 

The hairs are altered from the very first. In the early stage, the aper- 
tures of the follicles of the diseased hairs are generally more or less promi- 
nent or papillated, and the hairs are unnaturally brittle, dull, and dry, and 
are bent on themselves and twisted, so as not to lie smooth, and the roots 
are somewhat matted together by the furfuraceous scales. A little later, 
they break off at a short distance from the diseased surface, leaving the 
circular patches partially deprived of hair. The broken hairs are uneven 
in length, and otherwise altered in appearance, being bent and twisted, and 
having become lighter in color than the original hairs, so as to assume some- 
what the look of bundles of tow. The enlarged follicles also dot the surface, 
giving it the appearance of cutis anserina, or the skin of a plucked fowl. 
The epidermis and the stumps of the broken hairs now become covered with 
a characteristic grayish-white powder, consisting of the sporules of the tri- 
cophyton, the peculiar parasite; and, on examining the hairs, the same 
fungus will be found penetrating into the bulbs and shafts between the 
separated fibres, and causing here and there, by its accumulation, swellings 
or bulgin'gs of the shaft. 

The disease is unattended by any local sensations, excepting a moderate 
degree of itching. 

If the disease persist and the degree of inflammation increases, there 
may be a good deal of infiltration of the scalp, and the surface becomes 
tumid, and dotted with enlarged orifices of hair-follicles, or there may be 
an eruption of vesicles or pustules, which dry and form scaly, yellowish 
crusts. 



TINEA CIRCINATA — DIAGNOSIS. 055 

DiAGN0>i>5. — This disease is easily distinguished fmm other eruptions of 
the scalp. The appearances it presents when fully (loveK>]>cd, are utterly 
unlike those of favus or eczema i?n pet igi nodes capitis. In favus, the pecu- 
liar cup-shaped crusts and the presence of the spores of the achorion, are 
sufficient to prevent mistakes; while in eczema, the eruption is «jero-pustu- 
lar, with the formation of yellowish or brownish yellow crusts ; the patches 
are not circular, the hairs are healthy, the itchinor is extreme, and finally 
the disease is not contagious; in all of which particulars it differs entirely 
from the eruption of ringworm. 

Pityriasis capitis does not occur in circular })atches, but affects the whole 
scalp ; it is not parasitic nor contagious, and does not lead to so much al- 
teration of the hairs. 

Occasionally tinea tonsurans, cither from ilie irritation of scratching, or 
some other cause, may be associated with eczema impetiginodes, which to 
a great extent obscures the former disease, though a careful search will 
usually detect some of the characteristic broken stumps of hairs, loaded 
with the parasitic growth. 

PRCKiNOSi?. — Ringworm of the scalp is entirely devoid of danger, but is 
an exceedingly troublesome disease, as it is apt to spread to other chil- 
dren, and is often very difficult of cure. Its duration is very indefinite, 
and it not rarely leads to patches of permanent baldness. 

Tinea circinata, as we have already said, fretpiently occurs in con- 
nection with tinea tonsurans, appearing on the neck or face ; though it 
occurs also as an independent disease on any part of the body, and in pa- 
tients of every age. 

It begins as a little rose-colored, slightly elevated spot, which soon be- 
comes the seat of slight furfuraceous desquamation ; and extends circum- 
ferentially, healing in the centre, until it forms a large slightly elevated 
erythematous ring, inclosing a portion of sound skin. 

In other cases, minute vesicles form on the reddened inflamed ring. 
They follow the usual course of development, being at first transparent, 
then turbid, and finally drying into small thin scales. 

The size of the patch varies greatly, being in some instances small, not 
larger than a shilling, and in others presenting a diameter of two or three 
inches. When small, the redness covers the whole of the patch, but is 
much fainter in the centre than at the circumference; when large, the 
centre regains the natural color of the skin. Usually the ring is exactly 
circular, but at times it assumes an oval shape. 

If any hairs have been growing on the afltcted spot, they become brittle 
and changed, as before described. There are usually several such circles 
present, and in some cases they are formed in great numbers. The only 
symptoms accompanying the eruption are slight pricking, smarting, and 
itching in the part. 

Occasionally the parasitic growth invades the nails, which then become 
opaque, whitish, thickened and brittle. 

DiAr;NOSiH. — There are but few diseases with which there is any danger 
of confounding tinea circinata. It is distinpii.-hed from erj'thema circina- 
tum bv ti>.. irr^ater elevation of the marginal ring, by the presence of the 



956 TINEA. 

parasite, and by its contagious nature ; and the two last peculiarities serve 
to distinguish it from psoriasis circinata. 

According to McCall Anderson, and some other dermatologists, herpes 
iris is merely a form of this affection. 

Treatment. — The cases of tinea tonsurans that have come under our 
charge, have proved in many instances very rebellious to treatment. 

Strict attention should always be paid to cleanliness and hygienic rules ; 
and, if the disease be associated with any impairment of the constitution, 
cod-liver oil, iron, in the form of the syrup of the iodide in syrup of sarsa- 
parilla, arsenic, and bitter tonics, should be administered. 

The local treatment is, however, the most essential. Where the disease 
occurs on a part covered with hair, epilation is advised by some authori- 
ties, and it would in all probability facilitate and hasten the cure. 

Among the local applications which have proved most useful to us have 
been sulphuro-alkaline lotions, composed of 5j of subcarbonate of potash 
and 5ij of sulphur, to a pint of water, applied by washing with a sponge 
several times a day ; strong solutions of sulphite of soda ; and an ointment 
consisting of 5j of muriate of ammonia, mixed in an ounce of sulphur 
ointment, applied first at night by inunction, and after a time on rags. 

Alkaline remedies have also been much used by other observers, who 
recommend washing the scalp every morning with a lotion composed of 
gr. XXX or xl of carbonate of potassa or borax to a pint of water, and ap- 
plying in the evening an ointment containing ^'} of tannic acid to ^j of 
lard. 

Much more stimulating applications are, however, highly recommended, 
and often prove very serviceable. Thus Mr. Wilson advises a single ap- 
plication of the acetum cantharidis, or the stronger acetic acid; and 
Devergie recommends a solution of nitrate of silver, 5j to f^j of water. 

Various mercurial applications are also advised, as solutions of corrosive 
sublimate, the citrine ointment, or the following, recommended by Jenner : 

R. — Hydrargyri Ammonio-Chloridi, . . . gr. xx. 
Ung. Sulphuris, ^iv. 

Tarry applications may also be employed in obstinate cases, in the form 
of lotions, ointments, or soaps, containing tar, or oil of cade. 

Nayler speaks highly of a plan used by Mr. Coster, who saturates the 
part with the following mixture : 

R. — lodini, ^^^ij. 

01. Picis, ffj. 

This solution is to be rubbed in firmly with a piece of sponge on the end 
of a piece of wood or whalebone. It is allowed to dry on the part, and 
left until the cuticle and the black crust separate at the end of a week or 
ten days. 

In cases where many patches are present over the body, it is advisable 
to employ mercurial or sulphur vapor baths. 

It must not, however, be forgotten that these varieties of tinea are among 



CASES. 957 

the most obstinate disorders to which children are subject. The most 
faithful trial may be made with the remedies recommended above, for a 
long time, without success, and it is often necessary to persevere in their 
use for months; conjoining the treatment with a change of diet, and, when 
possible, with a change of residence, before the affection will be entirely 
and permanently cured. 

Cases. — The following cases may be taken as types of the aggravated 
form of tinea, after it has persisted a long time and become complicated 
"with secondary eruptions of eczema or pityriasis. It will be noticed that 
in the following records, all of the patients are stated to have been mark- 
edly scrofulous ; but this circumstauce must not have too much importance 
attached to it, since in the Home where these cases occurred, almost every 
one of the children presented unquestionable marks of the strumous dia- 
thesis. There can be no doubt, however, that tins condition of constitu- 
tion strongly favored the development of the disease, rendered it more 
severe and obstinate, and also favored the occurrence of the secondary in- 
flammatory eruptions. 

George T., aet. five, scrofulous, admitted to the Home in \SC>i, with bloedini; 
piles. Tinea tonsurans appeared two months after admission, and persisted with 
various fluctuations for eighteen months, when it became com}ilicated with eczema 
impetiginodes. Applications of tar and corrosive sublimate have been chiefly re- 
lied on. 

Nov. 3Qtb, 1866. Scalp covered with grayish-yellow crusts, one-fourth inch 
thick, in places running together or forming isolated lumps. A f«^w spots of 
tinea circinata on face and neck. The scalp is reddish, and, there is very little dis- 
charge from it. The hairs are sparse and broken. The cervical glands are much 
enlarged on both sides. On removing the crusts and examining the base, numerous 
exudation corpuscles and some spores of tricophyton were found; the epithelium 
not very granular. 

Poulticed to remove the crusts. Ordered iodide of iron and potassium inter- 
nally. 

December 4lh. Scalp quite clean from crusts, but remains reddish, with here 
and there bald patches. Numerous spores of tricophyton found in the hairs and 
among the epidermic cells. 

Solution of sod» sulphis (5J to Oss. water), applied morning and evening, and 
kept on during the whole time by means of folds of linen saturated in the solution, 
and covered with an oil-silk cap. 

December 16th. Much improved. Scalp cleaner, and less red. Some flat, thin, 
whitish scales over surface. Hairs more free from tricophyton, but numerous 
spores can still be seen by scraping moist surface beneath the thin crusts. 

Treatment continued, with ultiitiate success. 

William L., let 5; herediUry tendency to tuberculosis; scrofulous; cervical 
glands enlarged on both sides; admitted in 1865, and has had tinea ever since, 
many forms of treatment having been tried, but none with more than tcmpornry 
■access. 

November 30tb, 1866. The scalp it reddened and wax-like from infiltration, 
with patches of baldness. In places where the eruption ii oldest it is covered 
with whitish scales ; elsewhere, there are i»cattered or confluent grayish-yellow or 
yellow cru.*ts. Discharge of pale, thin, fetid pus. 

On examining the surface beneath the crust*, numerous pus-cells and spores of 
tricophyton, often aggregated Ujgf-ther, arc found. The hairs have lof«t their 
normaf appearance entirely, are bent, and where they emerge fi*pm the scalp, the 



958 ALOPECIA AREATA. 

shaft is swollen, with bulging outline. The shafts are covered with spores of tri- 
cophyton, and their longitudinal fibres separated by collections of the fungus. 
•Some of the -bulbs remain healthy, others are broken and apparently converted 
into masses of fungous spores. 

Ordered poultices to remove crusts ; iodide of iron and potassium internally. 

Decemher 4th. Scalp clean, with exception of minute white scales; shows bald 
glazed patches, with light, short, thin hairs. Ordered same application of sul- 
phite of soda as used in previous case. 

December loth. Immensely improved ; the large bald patches still covered with 
minute shining white scales, but few tricophj'ta to be seen. 

Charles L., £et. 4, admitted in May, 1866; hereditary tendency to tuberculosis; 
cervical glands slightly enlarged. Tinea soon appeared on the face and scalp, and 
in early part of November, thin flat grayish-yellow crusts formed over vertex, the 
rest of the scalp being covered with minute whitish scales. 

I^ovember 30th, 1866. Ordered poultices to remove crusts; iodide of iron and 
potassium internally. 

December 4th. Scalp comparatively clean. Patches of baldness, especially over 
parietal protuberances, with straggling, short, light-colored hairs. Abundant 
spores of tricophyton found. The hair-shafts much involved, collections of the 
parasite existing between the longitudinal fibres. The bulbs are also diseased, and 
seem to have become afl:ected just below the exit of the hair ; the bulb first becom- 
ing swollen at this point and then its sheath having become destroyed, so that the 
fungus forms a bed surrounding the shaft. 

Ordered same application of solution of sulphite of soda. 

December 16th. Yery much improved ; scalp smooth and clean, excepting above 
the ears, where there is on each side a collection of thin yellowish crusts. The hairs 
passing through these had numerous pus-cells adherent to their shafts, but the hair- 
bulbs seemed healthy, and no spores of tricophyton could be found on any of them. 



ARTICLE III. 

ALOPECIA AREATA. 

This affection, which is also known by the names of area and tinea 
decalvaus, is characterized by the loss of hair in circumscribed patches 
of round or oval shape. It is by no means a rare disease, and is much 
more common in children than in adults ; thus of 42 cases cited by Hutch- 
inson, 28 were under fifteen, 14 above that age. 

Cause. — There is still much doubt as to the essential cause and nature 
of alopecia areata, although it appears to us that the view which attributes 
it to a perversion or suspension of innervation is the correct one. 

Gruby is said to have discovered in 1843 a fungus in it, which has been 
called the microsporon Audouini, and some dermatologists of high au- 
thority accept the view of its parasitic nature. It cannot, however, be 
said to be demonstrated, since the parasite is very rarely found ; so that 
Andei*son, who has made numerous microscopic examinations, has never 
succeeded in detecting it. 



SYMPTOMS — DIAGNOSIS — PROGNOSIS — TREATMENT. 959 

"Wilson, Duhring, and many others, consider it as due to suspended in- 
nervation, as a kind of paresis. 

The disease appears to be, at least in some instances, propagated by 
contagion ; though it certainly possesses this property to a much less 
degree than either of the forms of ringworm. 

Symptoms. — The disease is limited to the scalp in children ; thougli in 
adults it may attack any hairy part. In some cases, the first intimation 
of the existence of the disease is the sudden discovery of a bald spot, but 
in others, though less frequently, there is slight itching, with redness and 
branny desquamation of the affected spot^. 

The bull)s of the haii-s then atrophy, and become tapering instead of 
being rounded and club-shaped ; the hairs themselves become dry, lustre- 
less, and brittle, with a fibrous fracture, and rapidly fall out, leaving bald 
patches. 

These patches vary in size from one-half inch to an inch or even more 
in diameter, and there may be but a single one present, or they may be 
numerous, in whicl> case they often coalesce, forming large patches of 
irregular shape ; when the patches are single they usually assume a round 
or oval form. 

The denuded portion of scalp is peculiar in appearance, being very white 
and polished, and thinner than the surrounding healthy scalp; the sensi- 
bility of the ati'ected surface is also frequently impaired. 

Diagnosis. — There can be no difficulty in recognizing the fully devel- 
oped disease, excepting in the comparatively rare cases when it is combined 
with other skin diseases, as eczema or pityriasis. 

Pro<^;nosis. — The only danger attendant upon alopecia areata is that of 
deformity, which is, in some cases, very great, depending of course upon 
the extent of the disease and the stage at which it is brought under treat- 
ment. 

If the patches are small, the scalp not materially atrophied, and the 
orifices of the hair-follicles still visible on the bald patches, there is good 
reason to hope that steady persistence in treatment will effect a cure. In 
the majority of instances, it may be said that recovery occurs after a 
length of time varying from .several weeks to several months. 

Treatment. — Those who regard this as a parasitic affection, advise the 
ablation of the hairs immediately surrounding the patch, and the applica- 
tion of s<»me of the stimulating parasiticide- •■....<.i,hu ended in ')'<• 'irflrl.. 

CD tinea. 

The majority of authors, however, content tht ninrlves with th» ajiplica- 
tion merely of such stimulating lotions and ointments as will incrca.^c the 
nutrition of the affected gpot«, and favor the renewed growth of hair. 

Among the ointments which are most highly recommended are those con- 
taining the red io<lide, the nitrate, the ammonio-chloridc of mercury ; some 
form of sulphur; or tar, io<line, or cantharide>. 

Hillier recommends, as the treatment he has found most useful, the ap- 
plication at long intervals of acetum cautharidis to the bald patches ; paint- 
ing them every other day with tincture of ir»diiie, washing the head twice 
a wct^k with soap and cold water, and applying a wash (consisting of one 



960 SCLEREMA. 

piDt of rum, one ounce of tinct. cantharidis, one-half ounce of spirit, am- 
monise aroraat., and ten ounces of water) to the parts of the head which 
are not bald, twice a week. 

The effect of this local treatment will be much increased by the internal 
administration of arsenic and iron. 

Alcohol, carbolic acid, ammonia, and capsicum have also all been highly- 
recommended as local applications in the treatment of this affection; they 
should of course be employed in a sufficiently dilute form. 



SECTION 11. 
AETICLE I. 

SCLEREMA. 



Definition; Synonyms; Cause; Frequency. — This peculiar affec- 
tion, characterized by induration of the skin and subcutaneous tissue, 
with or without oedema, has been described by numerous writers, almost 
each one of whom has given a distinct name and theory for the disease. 
Among these names the most appropriate are sclerema, scleriasis, sclero- 
derma, induration of the cellular tissue, or chorionitis. 

It is an affection not altogether peculiar to infants, though it is rare to 
find it well developed after the first few months of life. There are, how- 
ever, a sufficient number of cases in adults on record to establish the fact 
of its occasional occurrence at all ages. It must be a very rare disease in 
this country, even among infants, and especially in private practice, as 
we have met with but three well-marked cases in adults, and but one 
instance occurring in childhood, which was the case in which imperfect 
induration of the skin was developed in connection with atelectasis pul- 
monum, to which allusion is made in our article upon the latter affection. 

In the large foundling hospitals in Europe, however, where so many 
causes exist to depress the vitality of the infants, it is of very frequent 
occurrence. Under such circumstances, moreover, it generally develops 
itself within the first twelve or fourteen days after birth. 

The most varied causes were formerly assigned for this disease, before 
the researches of Bailly and Legend re appeared to point out sclerema as 
one of the results of imperfect expansion of the lungs. As we have already 
remarked, it is seldom observed among the children of the upper classes 
of society, so that all those conditions which depress the strength of the 
child, as insufficient or unhealthy nourishment, imperfect clothing, cold, 
especially when associated with moisture, may be considered as the predis- 
posing causes of sclerema. The inffuence of dampness and cold in develop- 
ing this affection is shown by the fact, deduced from numerous statistics, 
that twice as many children are attacked during the cold and wet months of 



SYMPTOMS. 9()1 

the year as at other times, although there are cases recorded as occurring 
iu the hottest months. 

Authors still ditler in regard to the relation hetween atelectasis and 
sclerema. We^t' accepts the results of the researches of Bailly and Le- 
gendre, and considers it a result of the imperfect expansion of the lungs. 
Bouchut,- on the other hand, regards the changes found in the lungs as 
the result rather than the cause of the induration of the skin. 

Letourneau' agrees with West in regarding sclerema as a condition 
depending primarily on congenital weakness, imperfect expansion of the 
lungs and defective hiematosis. According to his view it is a slow asphyxia, 
the hodv becominir irraduallv cooled down and the child remainin<r in a 
State of organic torpor until death occui-s. 

Symptoms. — The disease presents some variety of symptoms according 
as it occurs in early infancy or in more advanced life. 

In infants the induration of the skin ajipears witliin two weeks after 
birth, either with or without a preceding febrile condition for a day or two. 
It invades successively the feet, hands, limbs, the back, the face, and finally 
involves the entire surface of the body. At this early age, the skin retains 
its reddish tint iu the affected parts ; whilst later in life, the surface assumes 
a dull, slightly yellowish aspect. The skin becomes hard, is with difficulty 
pinched up, and instead of thinning, remains thick and waxlike. The parts 
appear somewhat swollen, though never to any great extent, and pressure 
with the finger scarcely leaves an impression on their surface. Occasion- 
ally the induration is associated with an effusion of serum beneath the skin, 
and when this exists, the surface is much more readily indented. 

It is this occurrence of redema which has led some observers to consider 
sclerema as a form of anasarca ; it is probable, however, that it,s presence 
is merely a result of the obstructed cutaneous circulation, and that it does 
not, in reality, constitute an essential element of the disease. The skin is 
also quite frequently jaundiced. The children usually preserve the power 
of moving the affected parts, and there is no loss of cutaneous sensibility. 
The temperature of the body, and especially of the indurated portions, 
rapidly decreases, so that from 100^ it may fall to 90°, 80°, and even, in 
some exceptional cases recorded by Roger, to 73^ and 70°. 

The little patients appear to sutler much pain during this disease. They 
utter a sharp, abrupt, i.solated, but very frequently repe^ated cry, quite 
characteristic of the afl^ection, and occasionally they present nervous symp- 
tom.*, such as twitching of the hands or more general convulsive move- 
ments. 

The strength fail.^ rapidly, and they soon become too weak to suck. The 
pulse is feeble, though not much accelerated, unless some complication has 
ensued. The appetite fails, and the bowels are constipated, unle.«s there is 
entero coliti-s, which occurs in a few cases. This condition is naturally 



> Diseases of Children (8d Amer ed.), p. 288. 

• Di»eii»e« of Infancy ^Bird's tron« ). 

• Letourneau, Sclerema and (Edema. Pari*, 1858 (Can»Ut. Jalirb., iv, 460). 

61 



962 SCLEREMA. 

attended with great emaciation, as we find in Elsasser's ^ cases, where the 
average loss of weight was three-fourths of a pound, the extremes being 
six ounces and two pounds. 

The respirations are imperfect, and, after a short time, cough makes its 
appearance and continues throughout the case, indicating the occurrence 
of either pneumonia or collapse of the lungs, which are by far the most 
frequent complications, even if the state of atelectasis be not regarded 
as an efficient cause of sclerema. The disease, however, is not always so 
general and severe as above described ; occasionally it occurs in limited 
portions of the body, and without any very alarming symptoms. 

In later life the disease is more frequently thus limited to small portions 
of the body ; the symptoms follow a more chronic course, and are somewhat 
amenable to treatment. Eilliet and Barthez ^ describe an acute and chronic 
form, and mention the following symptoms as distinguishing the disease in 
the adult : the severe epigastric pain associated with violent palpitations, 
the less acute progress of the case, and the more frequent implication of 
the serous membranes. 

In one well-marked case, occurring at the age of thirty-five years, which 
one of us had the opportunity of observing during its entire course, these 
symptoms were very prominent. 

Peognosis. — In infants, when the induration is at all general, the dis- 
ease almost invariably terminates fatally in from two to six days. Under 
favorable circumstances, however, and when the induration is limited, reso- 
lution may occur, and the case terminate favorably ; though it requires 
from fifteen days to a month to effect the cure. 

The fatal result is either caused by the gradual exhaustion of the vital 
powers, or by the supervention of one of the complications already men- 
tioned, by far the most usual of which are lesions of the lungs. 

In later life, when the disease tends to recovery, a long time may be 
consumed before the induration completely disappears. Eilliet and Bar- 
thez report a case, occurring in a girl aged eleven years, which lasted two 
years, although it was at no time very general or accompanied by very 
severe symptoms. 

Of 53 cases reported by Elsasser, all but 4 proved fatal, either from 
the sclerema itself, or from some incidental disease. 

Diagnosis. — The absence of any lesion of the internal organs, together 
with the perfectly characteristic appearances of the induration, render an 
error of diagnosis almost impossible. 

Anatomical Appearances. — The induration of the surface persists 
after death, and on incising the part, a turbid fluid, resembling that of 
anasarca, often flows out. The subcutaneous tissue is also indurated, and 
the fat is found in the form of solid granules. This layer, which varies 
from one-half a line to three lines in thickness, is sometimes followed by a 
gelatinous one. 

The fluid which is contained in the meshes of the tissues has been sub- 
jected to analysis by several observers, but with conflicting results : Chev- 

' Sclerema, Arch. Gen., N. S., t. i, 1853, p. 531. 2 Qp. cit, t. ii, p. 106. 



ANATOMICAL APPEARANCES. 063 

real and Breschet reporting that it contained a plastic matter, spontane- 
ously coagulable on contact with the air, which they were inclined to re- 
gard as characteristic of the disejise ; wliilst Billard, on repeating this 
observation with tliiid derived from an ordinary case of anasarca, found it 
to possess the same property. This subject, therefore, of much importance 
in regard to the pathology of sclerema, requires to be more fully investi- 
gated. 

Different observers are not agreed as to the condition of the coriuni and 
subcutaneous tissue. In sclerema adultorum the essential element in the 
changes of the skin appears to consist in a morbid increase of the connective 
tissue, associated with a marked development of lymphoid cells, by multi- 
plication of the cells in the perivascular sheaths of the minute bloodves- 
sels of the derm and subcutaneous tissue. This condition was pointed out 
by Rasmussen (translated in Ediu. Med. Journ., vol. xiii, part i, pp. 200 
and 318^, and accords with our own investigations. In sclerema in chil- 
dren, Jenks* and Loschner" have observed marked increase in the connec- 
tive tissue of the corium ; but this condition has not been found by other 
observers. 

The indurated tissue is traversed by numerous vessels, permeable, and 
for the most part gorged with dark blood. Bouchut believes that the 
cutaneous capillaries are in great measure obliterated in the indurated 
parts, and that the oedema which occasionally coexists with sclerema is 
due to this obliteration ; founding his opinion upon an unsuccessful at- 
tempt to inject the skin of a limb affected with sclerema, although the 
injecting fluid freely entered all the deeper tissues. The observatibns of 
Elsiis^ser, however, render this view doubtful, since in 49 cases, he failed 
to find this condition. 

Apart from these morbid changes in the skin and subcutaneous tissue, 
there is no lesion characteristic of sclerema. In a large number of cases, 
however, the lungs present some abnormal condition. According to Bou- 
chut, they are often gorged with blood, and here and there contain patches 
of lobar pneumonia: condition.-^ wliich he rcLMrds rather as the result than 
the cause of sclerema. 

Elsasser found lobular pneumonia pre.-rnt in a tenth of his cases; and 
in a third of them, portions of the lungs were impermeable to air. We 
have already stated that Wext, following the researches of Bailly and Le- 
geodre on atelectasis, believes that sclerema is one of the results of this 
persistence of the foetal condition of the lung, not differing in it« essential 
nature from cedema following pulmonary obstruction. The occurrence of 
undoubted cases of sclerema in the adult, and the frequent absence of 
atelectasis in well-marked cases of sclerema in infants, appear, however, 
to render this view untenable. 

The entire venous system and the cavities of the heart are distended 
with dark fluid blwd ; but the heart presents no constant condition to 
which could be attributed the production of the disease. The janndicc 

» Amer. Journ. of Obflclnc*, M«y, 1871, p 129. 
« Pragor, Vicrleljahr*cbrifl, 1868. 



964 SCLEREMA. 

which has been mentioned as occasionally existing, is not found to be as- 
sociated with any abnormal condition of the liver, excepting congestion. 
Eutero-colitis is a rather frequent complication of sclerema, and has been 
regarded as influencing its development ; but this view has long since been 
abandoned. Elsiisser found intestinal lesions and hypersemia of the ab- 
dominal viscera quite commonly; and in eight of his cases, peritonitis was 
present. 

Treatment. — The preventive treatment of sclerema consists in attention 
to all the hygienic conditions of the young infant. 

The curative treatment implies the removal of all the causes, and the 
application of remedies calculated to restore the force of the circulation, 
and the function of the skin. Warmth stands foremost as a curative 
measure, and recourse may be had to warm baths or hot vapor-baths, and 
to frictions with hot oil ; hot sand or bran-bags may be applied to the sur- 
face, and the temperature of the room should be Carefully regulated. 

The child should be nourished with breast-milk ; and stimulants, such 
as wine-whey, should be freely given. Cordial and aromatic draughts are 
also recommended, which may be formed of any of the diffusible stimu- 
lants. 

As there is reason to believe that some relation exists between sclerema 
and atelectasis pulmonum,we should, in addition, resort to all those means 
especially adapted to remove this condition, for a full account of which the 
reader may refer to the article on collapse of the lungs. 

The same plan of treatment is advisable in cases in adult life. 

By 'these means we may hope to arrest, and even cure this strange affec- 
tion, when it has not involved any considerable portion of the surface. 



CLASS VIII. 

WORMS IX THE ALIMENTARY CANAL. 



GENERAL REMARKS. 

There are five different species of worms found in the alimentary canal. 
These are the Ascaris lumhricoides, or round-worm ; Ascaris vermicularis, 
thread-worm, seat-worm, or, as it is popuhirly calle«l, ascarid&s ; Tricoceph- 
alus dispar, or lonp^ thread-worm ; Taenia solium, and Tivnia mediocanellata, 
the most common varieties of tape-worm ; and the Bothriocephalus latus, 
taenia lata, or broad tape-worm. 

We shall give a short description of each of the intestinal entozoa, in 
order that they may be readily distinguished, but will treat of the causes, 
symptoms, and treatment only of the first two. inasmuch as the ticnias very 
rarely exist during infancy or childhood, and the tricocephalus is much less 
fre<j[ueut than the round and seat-worms, and givo> ri-o to symptoms of 
the same kind as the former. 

Description. — The Ascaris lumhricoides, or, as it is commonly called, 
lumhricoides, lumbricus, or round-worm, is shaped not unlike the common 
earth-worm, having a cylindrical body, which is attenuated towards either 
extremity, but particularly the anterior. It varies in length generally 
between six and twelve inches, and is usually about two or three lines in 
thickness. The young worm, about an inch and a half long, is rarely met 
with. The head of the animal is at the smallest extremity, and may be 
distinguishes! by a circular depressioD, around which may be seen three 
tubercles. When recently voided, the worms are somewhat transparent, 
so that the viscera may sometimes be .seen through the ])ariotos. The in- 
tegument is marked by circular fibres, and by four line^ extending at equal 
distances from the head to the tail, the former of which indicate the course 
of the muscles, while the latter indicate that of the vessels and nerves. 

The color of the worm is whitish, yellowish, or more or le.«s deep rosy 
in tint, according to the nature of the aliment they contain ; they are, as 
already stated, somewhat transparent when first voided. The alimentary 
canal, which may be distinguished by it* brownish color, terminates by a 
transverse ofiening or anus, .situated on the inferior surface of the animal, 
just in front of its posterior extremity. 

The two sexes are in different individuals. The male may Ik* known by 
its tail, which is shortly curved, while that of the female is straighten aod 
thicker. The genitals of the male consist of a double penis, which may 
sometimes be seen to protnide just in front of the caudal extremity ; thoee 



966 WORMS. 

of tlie female may be distinguished by the vulva, seated at a constricted 
point of the body, about a third of the distance from the head to the tail. 
The male is smaller and much less abundant than the female. 

The Ascaris or Oxyuris vermicularis, thread- worm, seat-worm, or maw- 
worm, is the smallest of the intestinal worms, and is generally distinguished 
in popular language by the title of ascarides. The sexes are in separate 
individuals. 

The male is generally about two lines in length ; its body is elastic, of 
a whitish color, very slender, and looks not unlike a piece of cotton thread, 
whence one of its names was derived. The female is larger than the male, 
reaching a length of four or five lines. The anterior part of the body is 
of the same shape in both sexes. It is obtuse, and surrounded by a trans- 
parent membrane, through which may be seen a straight tube, forming a 
kind of bladder, which is the oesophagus, and which terminates in a glob- 
ular stomach. The head is provided with three tubercles, as in the lum- 
bricoides. The intestinal tube in the male continues the whole length of 
the body, which becomes somewhat thicker towards the end, and is arranged 
into a spiral shape at the tail. The body of the female is shaped like that 
of the male as far back as the stomach, and increases in size in the first 
third of its length, after which it diminishes, and becomes so small at the 
end as to be seen with difficulty by the naked eye. 

The Tricocephahis dispar, or long thread-w^orm, is generally about an inch 
and a half or two inches long, and consists, as it were, of tw^o portions, of 
which the anterior, constituting about two-thirds of the length, is exceed- 
ingly slender, scarcely thicker than a horse-hair, while the posterior third 
swells out suddenly so as to become much thicker and larger. The sexes 
are in different individuals. The worm is provided with an alimentary 
canal, which, commencing at an orbicular mouth placed in the small ex- 
tremity, runs through the animal to the anus, placed at the caudal ex- 
tremity. The male is smaller than the female, and is, usually, found con- 
voluted. This worm is met with chiefly in the coecum and colon, particu- 
larly the former. It usually exists in very small numbers, and sometimes 
but a single one is found. The symptoms which it occasions are the same 
as those produced by the lumbricoides. 

The Taenia solium, common or long tape-worm, as well as the Taenia lata, 
are of rare occurrence in children. Of 206 cases observed by M. Wavruch, 
only 22 occurred in subjects under fifteen years of age, and of them the 
youngest was three years and a half old (Bib. du Med. Prat, t. v, p. 626). 
These worms have, however, been met with at an earlier age, but as they 
are rare, we deem it unnecessary to do more than describe their appearance, 
in order that the reader may be able to distinguish between them and the 
varieties which generally exist in children, the Ascaris lumbricoides and 
vermicularis. For a full account of the symptoms produced by the two 
varieties of the taenia, and their treatment, the reader is referred to any of 
the standard works on the practice of medicine. 

The Tcenia solium is usually of a whitish color, flat in form, and varying 
in length from five to ten feet, its ordinary, length, to twenty feet, or even 
more. It is uneven in shape, being thick and broader behind, and meas- 



DESCRIPTION — FREQUENCY. 0G7 

uring three or four lines at its widest part, while it tapers gradually 
towards the anterior extremity, where it becomes slender and thread- 
like. The head is globose and very minute, being about 3'otli inch in di- 
ameter. It has a projecting papilla in the centre, furnished with a double 
circle of booklets. There are also four projecting suctorial c^isks placed 
at equal distances around the head. The neck is delicate and tliread-like, 
but on microscopic examination presents transverse wrinkling at a short 
distance from the head, and soon merges into the distinctly jointed bo<ly. 
This is composed of numerous segments, which at first are small, and 
broader than they are long, but lower down increase more raj>idly in 
length tlian in breadth. The largest joints measure about one-fourtliof an 
inch wide by half an inch long. Each joint contains both male and female 
sexual apparatus, opening by a common ajx^rture on the side. 

The Tivnia wietf/oca/jc/Za/a was formerly confounded with the ticnia solium. 
It attains however a greater length, its joints are longer and broader, and 
its head is about three times as thick. The four suckers are present, but 
there is no central projecting papilla, nor any booklets. 

The Bothriocephalus latw^y Ttcnia lata, or broad f<ipr-iconn, is long and 
flat like the preceding variety, but it is generally thinner and broader, 
measuring from four to ten lines in breadth. It attains even a greater 
length than the common tape-worm. It is usually of a dirty- white color, 
and rather less opaque than the taenia solium. It is distinguished also 
from the other tieniie, by the shape of the segments, which are broader 
than they are long; by the form of the head, which is small, elongated, 
without spines, and divided into two lobes by a longitudinal fossa on each 
side; and by having, instead of the four mouths of the tenia solium, a 
single minute pore in the centre, between the ^o:i^x, or else two j^ores, one 
at the extremity of each lobe. 

The frequency of intestinal worms, and their importance as a cause of 
disease, have certainly been, and are still by many physicians, and espe- 
cially by the public, very greatly exaggerated. There can be no doubt 
that they do, when they exist in large quantities, and particularly in cer- 
tain countries, give rise to great disturbances of the digestive organs, and 
even occasion death ; but such instances are, it seems to u^, extremely rare, 
in this city, at least. We are quite sure that we have never as yet met 
with a case, in our own experience, in which life was at all seriously en- 
dangered by their existence, — though we have seen numerous instances 
in which slight disorders of the digestive apparatus, and various nervous 
symptoms, generally of very moderate Kcvcrity, have disapjx'ared after the 
administration of anthelmintics, sometimes followed, and in an equal 
number of cases probably, not followed, by the expulsion of worms. 

To show the truth of the above remarks, as to the importance of worms 
as a cause of disease, we make the following (piotations: Dr. Rush (Afcd. 
Inquiries and Observations, vol. i, p. 20.'>; remarks: "When wc consider 
how universally worms are found in all young animals, and how fretpiently 
they exist in the human bwly, without producing di.<)ea.se of any kind, it 
is natural to conclude that they serve some useful and necessary purf>r>sc8 
in the animal economy." M. Guersant says {Did. dc Med., t. xxx, GG9) : 



968 WORMS. 

** It has always been the custom to assign to entozoa much too important 
an influence upon the diseases of childhood. In proportion as this part of 
pathology is perfected, it becomes evident that the greater number of chil- 
dren dying after having discharged worms, or even while having them 
still, are aflTected with acute or chronic diseases, which leave after death 
incontestable traces of their effects, and which are of themselves neces- 
sarily fatal." M. Barrier {Mai. de VEnf., t. ii, p. 100) quotes M. Trousseau 
as making the following remarks : " For sixteen years we have not met 
with a single child who has presented any verminous symptoms; never or 
almost never does a child born and reared in Paris discharge worms, while 

just the contrary is true as to the provinces Young children, to be 

sure, are sometimes met with in our hospitals, who discharge worms, but 
they are those who have been born in the country, and have lived in the 
capital only for a short time." Dr. Condie {Dis. of Child., 2d ed., p. 226), 
remarks : " Worms are a very common occurrence in the intestines of 
children, and may unquestionably, under certain circumstances, become 
a cause of severe irritation ; but much less frequently than is generally 
supposed." 

We believe we may conclude, therefore, that though these parasites are 
of very common occurrence, and productive of grave disorders in some 
countries, they are rarely met with in quantities sufficient to do serious 
injury to the health, in other places, as for instance Paris, and probably in 
this country, or at least in the northern parts of it. 

That intestinal worms do, however, not unfrequently in some countries, 
and occasionally in all, produce dangerous and even fatal disturbances of 
the health, cannot be doubted after careful perusal of the evidence brought 
forward by different authorities. M. Guersant, amongst others, remarks 
{loe. cit.f p. 670) : " It is nevertheless incontestable, that the development 
of these animals in the gastro-intestinal and abdominal cavities does some- 
times give rise to very varied morbid phenomena, which are in some in- 
stances grave enough to cause death." Nevertheless, we are disposed to 
believe, as stated above, that fatal or even dangerous results from the 
existence of these parasites are of rare occurrence in this city, and prob- 
ably throughout our Northern States. Dr. Dewees, however, mentions 
several cases in which they produced alarming symptoms, and one in par- 
ticular (Dis. of Child., p. 492), in which the subject, a child twenty months 
old, was extremely emaciated, and whose abdomen was " enormously dis- 
tended, and semi-transparent," who recovered rapidly after ninety-six 
lumbricoides, from six to ten inches long each, had been expelled under 
the use of pink-root in infusion. 



ASCARIS LUMBRICOIDKS. 969 

ARTICLE I. 

ASCARIS LUMBRICX)IDES. 

The de^'icnption of this worm has already been given at page 065. 

Causes. — Under this head we shall not pretend to consider the question 
of the origin of worms, but only the causes which predispose to tlicir pro- 
duction, or favor their growth. 

Age ha^ no doubt a considerable influence upon the predisposition to 
lurabricoides. According to M. Guersant (loc. ci7., p. 685), infants at the 
breast under six months of age are very rarely affected with them. In- 
stances occasionally occur, but are altogether exceptions to the general 
rule. Above six months of age, they begin to be met with, but still very 
rarely, so that scarcely one or two will be found in several hundred chil- 
dren of a very early age; while from three to ten years of age they will 
be observed in about a twentieth, or in some seasons perhaps in a larger 
proportion. M. Valleix states that he has never met with them in new- 
born children. Dr. Dewees says {loc. cj*f., p. 481), that he has never seen 
worms in children under ten months old ; and in only two instances at that 
age. We do not rei'ollect ourselves ever to have seen them in subjects 
younger than eighteen months, and very rarely in those under three or four 
years. 

There can be little doubt that the disposition to worms is hereditnnj in 
some families. It is generally believed that the species under consideration 
is more common in girU than boys; that it is most common in children of 
Ipnphafic and scrofulous constitutions ; and that a too exclusively vegetable 
or milk diff, and an abuse of fruih, strongly predispose to their production. 
The habitatiou of a cold and damp, or warm and damp climate, and the 
seasons of summer and autumn, are sujiposod by many also to favor their 
production and growth. It is a general belief, and we should suppose from 
personal experience, a well-founded one, that a feeble and disordered state 
of the digestive finution from any cause, often acts as a predisf^siug cause 
of worms, and particularly of lumbricoides. 

Seats. — The small intestine is, in a ven.' large majority of the cases, the 
seat of the ascaris lumbricoidei*. They are met with, however, in other 
part* of the digestive tube, particularly the stomach and large inte.**tine, 
and more rarely in the <PSophagns or pharynx, f n some instance's they are 
found to have migrate<l to other organs, as to the liver, gall-bladder, and 
io still rarer ca^s they have pa.S8ed into the peritoneal cavity, bladder, 
larynx, trarhea, bronchia, and even into the nasal passages and frontal 
einusci*. They have also been met with occasionally in the walls of the 
abdomen, forming verminous abscesses, whence they have esca|>ed on the 
opening of the abscess. 

The number of a>*caridcs is exceedingly variable; there may be only two 
or three, ten or twenty, or sevfral hundred. Whf-n very numerous, they 
are apt to be rolled or twisted into kii<»t-< or baIN, wliirh have been seen aa 



970 ASCARIS LUMBRICOIDES. 

large as the fist, so as to block up completely the canal of the intestine. 
In a case cited by Rilliet and Barthez, from M. Daquin, the duodenum 
was so filled with worms as to be distended, and to have acquired a con- 
siderably larger size than natural, while at the same time it was hard and 
elastic. The jejunum, ileum, and caecum were filled, so that it seemed as 
though the worms must have been pushed in by force. They were found 
also, but in smaller quantity, in the colon. Dr. Condie {loc. cit, p. 230) 
states that he has known one hundred and twenty lumbricoides to be voided 
in a single day by a child five years old. It ought, however, to be remarked, 
that the instances in which such large numbers are met with are altogether 
exceptional, especially in our Northern States. We have never ourselves 
known more than six, eight, or ten to be expelled within a few days' time, 
and very generally there have not been more than three, four, or five. 

Anatomical Lesions. — When the number of lumbricoides is small, 
the mucous membrane has been found in a state of perfect health, while, 
on the contrary, when they are numerous, and especially when collected 
together into knots, the membrane has presented a fine injection like that 
which exists in erythematous enteritis; in some very rare instances on 
record, in which the quantity of worms has been very great, the mucous 
membrane has been found deeply injected, thickened, granulated, and, in 
a small proportion of cases, softened, and even eroded. Not unfrequently 
the intestine presents all the characters of well-marked enteritis, or entero- 
colitis, though the number of worms may be very small. In such cases, it 
is reasonable to suppose that the inflammatory affection has been an acci- 
dental complication of the verminous disorder. 

Much discussion has arisen in regard to the manner in y^hich. perforation 
of the intestine, as an accompaniment of worms, takes place. It is neces- 
sary to suppose, in subjects in whom worms are found in the peritoneal 
cavity, or in abscesses formed in the abdominal parietes, that perforation 
of the bowel has taken place, and yet in some instances no trace of the 
opening is left, no inflammation of the serous membrane is met with, nor 
has there been any escape of the contents of the digestive canal into the 
abdominal cavity. In others, however, and much the most numerous cases, 
it is evident from the anatomical appearances, that the perforation has 
taken place in consequence of previous ulceration of the coats of the bowel, 
and that the worms have escaped with the other contents of the intestine. 
It is in regard to the former class, therefore, that discussion has principally 
taken place ; some asserting that the parasite itself makes the opening, by 
an active process, while others deny the possibility of this occurrence, and 
maintain a previous ulceration or softening in all cases. Amongst those 
who advocate the possibility of perforation independent of previous change 
in the intestinal coats by disease, are MM. Mondiere and Charcelay, the 
former of whom has examined the subject with a great deal of care, quoted 
by Rilliet and Barthez ; Rilliet and Barthez themselves ; the authors of 
the Biblioth. du Med. Prat, and M. Guersant ; while amongst those opposed 
to this opinion may be cited, MM. Cruveilhier, Barrier, Dr. Arthur Farre, 
who greatly doubts the possibility of the accident, and Dr. Condie. We 
confess ourselves inclined to believe, from facts stated by different authors, 



ANATOMICAL LESIONS — SYMPTOMS. 971 

and from the history of two cases which occurred to M. Guersant in 1841, 
at the Children's Hospital of Paris {loc. cit., p. 680), that worms may in 
some instances cause a perforation independently of previous disease of the 
coats of the intestine. In one of these, two lumbrici were found engaged 
in an opening in the appendix vermiformis, half the bodies of the animals 
being in the appendix and half in the peritoneal sac ; while in the other, 
an opening of the same kind as in the previous case was found in the ap- 
pendix, and though the three worms which were found lying in the abdom- 
inal cavity might have escaped through an ulcerated perforation of the 
colon, it is not the less true that the opening in the appendix presented the 
same characters exactly as in the first case, in which the animals were, as 
the author remarks, " taken in the act." In both instances, the perfora- 
tion of the appendix was at the extremity of that canal, and in the form 
of a narrow opening of a conical shape; the membranes were smooth, 
thinned, and the edges of the orifice sloped off from within outwards; no 
trace of anterior ulceration was perceptible. On the other hand, we have 
met with a fatal case of intestinal perforation, dependent on extensive ul- 
ceration of the bowel, in which a lumbricoid worm was found lying loosely 
half-way out through the opening. In this case it was evident that the 
presence of the worm was purely accidental. 

In regard to the verminous abscesses already refered to, w^e shall make 
but few remarks, referring the reader to more extensive treatises for fuller 
information. These abscesses have been, in very rare instances, met with 
in the pharynx and nasal passages, but much more frequently they exist 
in the abdomen. The latter may be of two kinds, stercoraceous and no7i- 
stercoraceous. In the former, the abscess, which forms upon some por- 
tion of the walls of the abdomen, gives issue not only to the worm or 
worms, and pus, but also to fecal and even alimentary substances, and 
leaves behind a fistula connecting with the cavity of the intestine, which 
may cicatrize after a short time, or remain open during life. In the other 
form of abscess, the opening through the coats of the intestine has been 
closed immediately after the passage of the worm, so that the abscess gives 
issue only to the animal and pus, after which it heals up without giving 
rise to a fistula. 

The verminous abscesses are said to be found generally about the in- 
guinal and umbilical regions; to occur most frequently between the ages 
of seven and fourteen years, and not to be, as a general rule, very danger- 
ous to life. 

Symptoms Indicative of the Presence of Worms.— We believe 
it is almost universally acknowledged by later writers, that there is no 
single symptom, nor group of symptoms, other than the expulsion of the 
worms, and their detection, which indicate with certainty their existence 
in the digestive tube. This is the expressed opinion, amongst others, of 
MM. Guersant, Rilliet and Barthez, Barrier, Valleix, and Drs. Eberle and 
Condie, and it is also the opinion Avhich we have ourselves been led to 
form from our experience amongst children. 

Another point worthy of remark is, that even though one or several 
worms may have been expelled, it is not always fair to conclude that the 



972 ASCARTS LUMBRICOIDES. 

symptoms under which the child labors, are the result of the presence of 
others of these animals, as there may be no more in the bowels, or they 
may be so few in number as not to produce injurious effects ; while, on the 
contrary, various disorders of the digestive tube, as chronic indigestion, 
simple diarrhoea, and inflammatory diseases of the gastro-intestinal mucous 
membrane, may and do exist simultaneously with, and yet independently 
of, the presence of these parasites. 

The symptoms generally enumerated as indicative of the presence of 
worms are the following. The child presents various signs of disturbed 
health. The stomach is more or less deranged, as shown by furred tongue, 
eructations, variable appetite, which is sometimes diminished, and some- 
times increased, thirst, acid or heavy breath, and nausea. The abdomen 
may be enlarged or retracted, generally the former, and is often more or 
less hard and painful to the touch ; the condition of the bowels varies in 
different cases, as they are spmetimes costive, and sometimes affected with 
diarrhoea. According to M. Guersant, the stools often contain glairy sub- 
stances, and are sometimes streaked with blood and of a yellowish-green 
color; the patient often suffers from colics, which may be either dull or 
acute, though more generally the latter, and which are generally felt at 
the umbilical region. Children affected with lumbricoides are said to pre- 
sent a peculiar physiognomy ; the face is usually paler than natural, and 
sometimes has a leaden tint ; the eyes are surrounded by bluish rings, and 
have at the same time a dull and languid expression ; the inferior eyelids 
are often swelled and puffy ; the sclerotic coat of the eye assumes a bilious 
tint; the nostrils are said to be sometimes swelled, and the child com- 
plains much of irritation and itching of those parts, and is constantly 
picking at them with the fingers. In some instances epistaxis takes place. 
The child is generally pale and thin, indolent and languid, or irritable 
and unhappy. The sleep is almost always disturbed. This indeed is, it 
seems to us, one of the most important signs both of worms and of chronic 
functional disorders of the stomach and bowels. The nights are almost 
always restless, the patient either waking often to drink, or waking in 
fright and alarm from dreams, or else constantly tossing and turning in 
sleep, moaning, or grinding the teeth. 

Other symptoms mentioned by different observers, and by some very 
much depended upon, are acceleration with irregularity of the pulse, and 
dilatation, especially unequal dilatation, of the pupils. We might cite 
also strabismus, and occasionally cough. 

In children in whom the number of lumbricoides is very large, the con- 
stitution suffers to a dangerous degree. The symptoms above enumerated 
are very marked, and at the same time the child is very pale or sallow, 
emaciated, weak, and without appetite ; the abdomen is hard and tumid ; 
the nervous symptoms are severe, and some of the symptoms which we 
shall describe presently, under the head of disorders occasioned by worms, 
are also observed. 

It should be remarked, however, again, that all or any of the symptoms 
just described may exist independently of the presence of worms, the only 
certain sign of which is their expulsion from the patient. 



I 

I 



I 




mechanical' EFFECTS. 973 

Morbid Effects occasioned by Worms. — MM. Rilliet and Barthez 
divide the accidents or effects produced by the existence of lumbricoides 
into two groups : those which result from the mechanical influence of the 
entozoa, as their accumulation or displacement ; and those which appear 
to be the consequences of a purely sympathetic action on the different 
systems of the body, and particularly the nervous system. 

Mechanical Effects. — Under this head are included perforation and 
hsemorrhage of the intestine, enteritis, abscesses, and the symptoms deter- 
mined by the displacement or migration of the worms into the ductus 
communis choledochus, the liver, or the air-passages. 

Of perforation and abscesses, we have already treated under the head 
of anatomical lesions. Haemorrhage is a very rare event, but it occurred 
in one instance cited by MM. Rilliet and Barthez, and Guersant, from 
M. Charcelay, in consequence of the rupture of an arteriole in a small 
rounded ulceration in the duodenum, apparently occasioned by the pres- 
ence of a large number of lumbrici. Enteritis, as an effect of the pres- 
ence of worms, has also been referred to under the head of the anatomical 
lesions. In many instances it is, no doubt, a mere accidental complica- 
tion, in no way connected w^ith the presence of entozoa ; probably this 
is true of a large majority of the cases. When, however, the number 
of the parasites is very great, and particularly when they are collected 
into large or firm knots and bundles, they may, no doubt, occasion, by 
their mechanical irritation, inflammation, thickening, softening, and even 
destruction of the mucous tissue, as in cases cited by M. Guersant, from 
MM. Bretonneau and Charcelay, and in one which occurred to himself. 
It should be remarked, however, that the cases on record in which ulcera- 
tions evidently depended upon the presence of worms, are, so to speak, 
infinitely few in comparison with those in which no such alteration ex- 
isted, or in which it was evidently independent of any influence exerted 
by the worms. 

Effects caused by the Displacement or Migration of Worms. — 
Lumbricoides have been found, as we have already seen, in the walls of 
the abdomen, giving rise to abscesses. They have been discovered, also, 
in the vermiform appendix, in the ductus communis choledochus, in the 
gall-bladder, in the hepatic ducts in the substance of the liver, forming 
abscesses, and in the pancreatic canal. The symptoms occasioned by the 
latter class of cases are very obscure. In one instance, M. Guersant sup- 
posed that an attack of convulsions depended upon the presence of worms 
in the common duct. 

More numerous examples are on record, in w^hich violent dyspnoea and 
cough, and fatal asphyxia, have occurred in consequence of the pressure 
of lumbricoides which had passed into the oesophagus, or from their in- 
troduction into the larynx, trachea, or bronchia. The symptoms occa- 
sioned by these accidents are a sudden attack of dyspnoea, anxiety, agita- 
tion, threatened suffocation, dry, spasmodic cough, acute painful cries, 
pain in the larynx or trachea, and, unless relief be obtained in a few 
hours, death. This kind of attack may depend on the rising of a worm 
or bundle of worms into the oesophagus, causing pressure on the larynx 



974 A«SCARIS LUMBRICOIDES. 

and trachea, as in the case reported by M. Tonnelle, in which the symp- 
toms disappeared after the expulsion of a large number of worms; or else 
it may be due to reflex spasm of the oesophagus or larynx dependent upon 
the irritation transmitted from the intestine which is excited by the pres- 
ence of these parasites. One of us has met with an instance of this kind. 
It occurred in a boy fifteen years old, presenting every mark of strong and 
vigorous health, but who, for three or four weeks before we were consulted 
in regard to him, had been subject to sudden and apparently causeless at- 
tacks of sujBTocation, which seized him without the least warning. When 
the attack came on, he would for some instants cease to breathe, or breathe 
with much difficulty. He always seemed to suffer from the greatest anx- 
iety ; the countenance became altered and distressed ; he was unable to 
speak, but made signs for water, and when able to swallow a mouthful, 
which was always exceedingly difficult, was at once relieved. His mother 
told us that he always appeared to be in the greatest distress, so that, on 
several occasions, she feared for his life. Striking him violently on the 
back, which she, when present, always did, sometimes relieved him, but 
generally the difficulty continued until he could swallow a little fluid of 
some kind. These attacks were unattended at the time by cough, nor was 
there the least sign of disorder of the respiratory system in the intervals 
between them. Suspecting that the difficulty must depend on the rising of 
a worm or worms into the oesophagus, or upon sympathetic irritation from 
the presence of these parasites in the stomach, and learning that he had 
been troubled with worms some years previously, we gave him wormseed 
oil, which caused the expulsion of a few large lumbricoides, after which 
he had no return of the symptoms. 

The attacks of dyspnoea may depend also, as already stated, on the 
introduction of worms into the air-passages. Under these circumstances 
death is very apt to be the result. In one instance, however, reported by 
M. Arronsshon, after the difficulty had lasted two hours, the patient, a 
little girl eight years old, after violent efforts at coughing, threw up a 
living lumbricus. 

We have next to consider the sympathetie effects, and particularly the 
nervous symptoms, occasioned by worms. We may include amongst the 
nervous symptoms produced by worms the headache, languor, irritability, 
restless and disturbed sleep, and grinding of the teeth, so frequently ob- 
served. These, however, are of but slight importance in comparison with 
certain other disorders of the nervous system, which do undoubtedly occur 
sometimes, though we should suppose very rarely, in proportion to the whole 
number of subjects affected with the parasites. The disorders to which we 
allude are partial or general convulsions, chorea, hysteria, and catalepsy, 
which are the most frequent, though, as so often stated already, extremely 
rare in comparison with the number of cases in which the presence of the 
worms produces no such effects. Other disorders cited by the authors of 
the Bib. du Med. Prat, with cases to prove their reality, are insanity, 
paralysis, coma, palpitations, strabismus, cough, hypersesthesia of the skin, 
amaurosis, and aphonia. 



DIAGNOSIS — PROGNOSIS. 975 

Diagnosis. — It has already been stated that there are no certain signs 
of the presence of worms in an individual except their expulsion. The 
symptoms which have seemed to us most strongly to indicate their presence 
are, a chronic disordered state of the digestive apparatus, producing irreg- 
ular apjjetite, which is sometimes good and at others bad ; slight emacia- 
tion ; paleness or unhealthy tint of the complexion ; languid expression of 
the face ; some irritability of the temper, or a want of the gayety and ac- 
tivity of disposition natural to childhood ; picking at the nose; often some 
tumidity of the abdomen, which may be at the same time either hard or 
merely tympanitic ; and, what seems to us more important than any that 
we have named, very restless and broken sleep at night, with frequent 
grinding of the teeth. 

M. Valleix remarks that, in a case presenting nervous symptoms simu- 
lating disease of the brain, we may suspect the existence of worms, if we 
learn upon inquiry that symptoms of marked intestinal disorder, the various 
signs cited above as indicative of the presence of worms, and different de- 
rangements of digestion, had preceded for some time the appearance of the 
nervous symptoms ; chiefly for the reason that, in most diseases of the brain, 
the digestive tube is, at the invasion, in a state of integrity, with the excep- 
tion of sympathetic vomiting. If we can learn, upon inquiry, that the 
child has discharged worms on some previous occasion, the probability of 
the dependence of the symptoms upon them becomes still stronger. 

It is sometimes difficult to determine positively whether certain sub- 
stances discharged at stool are fragments of worms, or whether they are 
portions of imperfectly digested aliment, or foreign bodies. The things 
which most resemble lumbricoides, are the remains of tendons, ligaments, 
vessels, fibres of plants, etc. To make the distinction with certainty, the 
doubtful substance ought to be placed in water, so that it may be thoroughly 
cleansed, after which it must be carefully examined as to its structure, ar- 
rangement, consistence, etc., with the eye, and with the microscope, if 
necessary. M. Guersant has suggested a very easy method of ascertaining 
whether the substance be animal or vegetable, which is to subject it to 
heat, after it has been carefully washed, when the odor will at once inform 
us of its real nature. 

Prognosis. — It is no doubt a very rare event, at least in the northern 
parts of our country, for life to be endangered by the presence of worms. 
We have never, ourselves, met with an instance in which the general 
health was more than moderately disturbed by this cause. That vermin- 
ous affections are sometimes, however, dangerous to life in this city, is 
shown by three cases related by Dr. Dewees, in which very severe and 
threatening symptoms were instantly relieved upon the expulsion of lum- 
brici after the exhibition of vermifuges. 

Worms become dangerous to life when they migrate from their original 
seat to neighboring and important organs, particularly the air-passages 
and liver. The prognosis is unfavorable also when they accumulate in 
very large numbers, and give rise to the different nervous symptoms above 
described. 



976 ASCARIS LUMBRICOIDES. 

Treatment. — Before commeDcing our remarks upon the particular 
remedies employed for the destruction and expulsion of worms from the 
alimentary canal, we would call the attention of the reader to the fact 
that most of the recognized anthelmintics are more or less irritating to the 
gastro-intestinal mucous membrane, and some of them to the nervous 
system also, producing, in . overdoses, severe and even dangerous nervous 
symptoms. It is evident, therefore, that remedies of this class ought not 
to be exhibited unless they are manifestly called for, and not at all when 
symptoms of severe gastro-intestinal irritation, and particularly of inflam- 
mation, are present, unless there be the very strongest reasons for supposing 
that those symptoms depend upon accumulations of worms. We are quite 
sure that we have, in a considerable number of instances, met with children 
whose digestive organs had been injured, and in whom slight functional 
derangement had been converted into severe indigestion, and even inflam- 
matory disorder, by the too frequent or long-continued use, or the adminis- 
tration in excessive quantities, of different vermifuges, and of various quack 
nostrums, which are sold to an amazing extent in this city, and all over 
the country. 

As the diagnosis of worms is always doubtful, it is best never to risk the 
administration of any of the irritating vermifuges, unless convinced, by the 
previous expulsion of worms,, that they are almost certainly present ; and, 
indeed, we ourselves rarely give any other remedy than small quantities of 
the wormseed oil in slight, and especially in doubtful cases, unless this has 
already been tried and failed. From our own experience, we believe that 
this remedy is all-sufficient in a large majority of the cases that occur in 
this city ; as these are almost always of a mild character, and, as it not only 
produces the expulsion of the parasites when they exist, but also acts bene- 
ficially upon the forms of digestive irritation which simulate so closely the 
symptoms produced by worms. We are persuaded, indeed, that of all the 
cases that have come under our notice, in which it seemed probable that 
worms might be present, none were expelled in nearly half, and yet the 
signs of disturbed health have passed away under the use of the remedy. 
The oil of wormseed may be given in doses of four drops to children of two 
years of age, and of six or ten to those above that age, three times a day 
for three days, to be followed on the morning of the fourth day by a 
moderately active, but not irritating cathartic dose, the best of which is 
castor oil or syrup of rhubarb. The objection to the remedy is its nauseous 
taste and smell ; these, however, may be partially disguised by making it 
into a mixture with yolk of egg, powdered gum, and syrup of ginger. 
Some children take it very well dropped, upon a lump of white sugar, while 
others take it best mixed with common brown sugar. If one course of the 
oil, as it is called, fail to relieve the symptoms, another should be ad- 
ministered. It ought to be recollected that, when given in large doses, 
the wormseed oil is irritating to the digestive mucous membrane, and pro- 
duces dangerous nervous symptoms. We know of one case, in which a 
girl six or seven years of age was made exceedingly ill and suffered for 
years afterwards, from the effects of a teaspoonful of the oil given by mis- 



TREATMENT. 977 

take. The following is a very good formula for the administration of this 
remedy : 

R. — 01. Chenopodii, gtt. Ix vel f^j. 

P. G. Acaciae, . . . . . . • ^ij- 

Syrup. Simp., f^j. 

Aq. Cinnamom., f^ij. — M. 

Give a dessertspoonful three times a day, for three days, and repeat after several 
days. 

The wormseed may be given also in powder, in the dose of from twenty 
to forty grains. 

The remedies most frequently employed in this country besides the 
wormseed, are pink-root or spigelia, oil of turpentine, calomel, and the 
bristles of cowhage. 

We believe that the pinJc-root is more depended upon amongst us than 
any other single remedy. It is given either in substance or infusion. The 
dose of the powder is from ten to twenty grains for a child three or four 
years old, to be repeated every morning and evening for several days, and 
followed by an active cathartic. The powder is seldom used, however, as 
the drug is almost always given in infusion. The best and safest mode of 
administering it is in combination with cathartic substances. Thus, half 
an ounce each of pink-root and senna may be infused for a few hours in 
a pint of boiling water, and a tablespoonful given two or three times a 
day to children two or three years old, for three, four, or five days, when 
it should be suspended for a time, and resumed, if necessary. A prepara- 
tion much used in this city under the title of worm-tea, and which we 
have ourselves given with very good success, consists of the spigelia mixed 
with senna, manna, and savine, in different proportions, made into an in- 
fusion and sweetened with brown sugar. Dr. G. B. Wood (Pract. of 3Ied., 
vol. i, p. 626) recommends the following formula: 



R. — Sennae, Spigol 



SfOllJ 



Magnesiae Sulphat., 
Mannge, . 
Foeniculi, 
Aquie Fervent , 



aa ^ss. 

. Eh 

. Oj. 



These are to be macerated for two hours in a covered vessel, and a table- 
spoonful given to a child two years old once or twice a day, or every other 
day, so as to procure two or three evacuations in the twenty-four hours. 
The remedy is continued for a few days, or for one or two weeks, if neces- 
sary, and if it do not debilitate the child. 

The fluid extract of spigelia and senna has been introduced as a more 
convenient and acceptable mode of administering this vermifuge with a 
cathartic. The dose for a child is from thirty minims to a teaspoonful, 
according to the age. 

The spirit of turpentine is highly recommended as an efficient remedy 
for worms by several authorities, and particularly by Dr. Joseph Klapp 
and Dr. Condie, of this city. Dr. Condie states that it is the article from 

62 



978 



ASCARIS LUMBRICOIDES. 



which he has derived the most decidedly beneficial effects, and remarks 
that it may be given when there exists considerable irritation of the ali- 
mentary canal, or even subacute inflammation, without any fear of its in- 
creasing either. He gives the rectified spirit in sweetened milk, in mo- 
lasses, or in the following mixture : 



Mucil. G. Acacise, 


• . f|y. 


Sacch.Alb., 


. 3x. 


Spir. JEther. Nitr., 


. • f3"J. 


01. Terebinth., ...... 


. . f^iij. 


Magnes. Calcinat., 


. . Bj- 


Aquae Mentha©, 


. . f5J.-M 



Of this mixture a dessertspoonful is given every three hours. 



We have used the spirit of turpentine but seldom, on account of its ex- 
tremely disagreeable taste, having always succeeded perfectly well with 
the wormseed oil, or with infusion of pink-root with cathartics. 

Calomel also is highly thought of by many persons as a vermifuge, and, 
no doubt, when used in combination with or followed by cathartics, or 
given in full purgative doses, it is very effectual. We can only repeat 
what we have already said on several occasions, that it is a remedy which, 
from the powerful influence it exerts upon the constitution, ought not to 
be given except when really called for ; and, as we can almost always suc- 
ceed in curing verminous affections by milder drugs, we see no occasion 
for resorting to this, except in rare cases. When used it is given alone in 
considerable doses, and followed by some cathartic, or in combination with 
rhubarb and jalap, or jalap, or scammony. 

The bristles or down of cowhage are also used by some practitioners, no 
doubt sometimes with success. We have never used them, and can give 
no opinion, therefore, from personal experience, as to their eflficacy. They 
are administered by making them into an electuary with honey, syrup, or 
molasses, a teaspoonful of which is given every morning for three days, 
and then followed by an active cathartic. 

The following electuary, recommended by Bremser, is very much em- 
ployed in Europe, and is highly spoken of by Dr. Eberle : 



H- — Semin. Santoniese (semen-contra of the French writers), 
Semin. Tanaceti rude contus., . . . . aa ^ss 
Valerian, pulv., 
Jalapse pulv., . 
Potass. Sulphat., 
Oxynnel. Scillse, 



SJss.-ij. 

q. s.— ut ft. 
Electuarium. 



A teaspoonful of this is given morning and evening for three or four days, 
when the dejections generally become more copious and liquid. If it do 
not produce this effect, B-remser advises that the dose be increased. Dr. 
Eberle gave it for six or seven days, and says it does far less good when 
it produces frequent and watery evacuations, than when it causes only 
three or four consistent stools a day. This preparation has a very dis- 



TREATMENT. 979 

agreeable taste, and children sometimes refuse to take it on that account. 
When this is the case it may be made into pills. 

MM. Rilliet and Barthez recommend the following syrup, which was 
i3roposed and highly thought of by M. Cruveilhier : 

R. — FoUicul. Sennae, Rhei, Semin. Santonic, Artem. Abrotan., 

Helminthocort., Tanaceti, Artemis. PoDtic, . . . aa gj. 

To be infused in half a pint of cold water, strained, and made into a syrup with 
sugar, of which a tablespoonful is to be given every morning for three days. 

Of late years, santonin, the active principle derived from the European 
wormseed, has been much employed, and with very good success. The 
remedy may be given in doses of from gr. ij to gr. v, combined or followed 
by a dose of castor oil or senna. It is also prepared in the form of sugar- 
coated dragees, which renders it quite acceptable to children. 

The empyreumatlc oil of Chabert is also highly spoken of by some 
European authorities. It is made by mixing one part of the empvreu- 
matic oil or fetid spirit of hartshorn, with three parts of spirit of turpen- 
tine, and allowing them to digest for four days. The mixture is then put 
into a glass retort and distilled in a sand-bath until three-fourths of the 
whole have passed over into the receiver. The product should be kept in 
small and tightly-closed vials. The dose is about fifteen or twenty drops 
three or four times a day, for children between two and seven years old. 
This is recommended highly by Bremser and other authorities. The great 
objection to it is its exceedingly nauseous taste. Dr. Eberle speaks in very 
favorable terms of a strong decoction of helminthocorfon or Corsican moss, 
which he has found "not only valuable as a vermifuge, but particularly 
so as a corrective of that deranged and debilitated condition of the ali- 
mentary canal favoring the production of worms." An ounce of helmin- 
thocorton, with a drachm of valerian, are to be boiled in a pint of water 
down to a gill, and a teaspoonful of the decoction given morning, noon, 
and evening. It is particularly beneficial in cases attended with the usual 
symptoms of worms, connected with want of appetite and mucous diarrhoea, 
and arising from debility of the digestive organs, and a vitiated condition 
of the intestinal secretions. 

Kameela, the reddish-brown powder which clothes the capsules of the 
Rottlera tinctoria, has been of late highly recommended, not only in cases 
of tjfinia, but of ascaris lumbricoides. The dose for children is about gr. 
V, repeated till it has acted on the bowels. 

In all cases of deranged health supposed, either from the nature of the 
symptoms, or proved by the previous expulsion of worms, to depend on the 
presence of these animals in the alimentary canal, it is. exceedingly impor- 
tant to attend to the hygienic treatment of the child, and in some instances 
to administer tonic^s and stimulants. In not a few cases that have come 
under our own notice, in which many of the symptoms supposed to indicate 
the presence of worms have been extremely well marked, we have succeeded 
in removing them all without a resort to any vermifuge, by the treatment 
proper for the chronic indigestion or dyspepsia of children. The method 



980 ASCARIS LUMBRICOIDES. 

of treatment to be employed in such cases has already been laid down in 
the article on indigestion, to which the reader is referred for full informa- 
tion. It should consist chiefly in strict attention to exercise and diet, and 
in the use of tonics, as quinia and iron, and small quantities of fine port 
wine. 

Whenever any complication exists in connection with worms, the treat- 
ment must be modified according to its nature. If it consist in inflamma- 
tion of any part of the digestive tube, the inflammation ought to be at- 
tended to first, and the verminous disorder for the time neglected. If the 
inflammation be very slight, or if the symptoms indicate only severe irri- 
tation rather than positive inflammatory action, we may exhibit the milder 
and least injurious vermifuges, as very small doses of wormseed oil, which 
we have never known to do harm, the decoction of helminthocorton and 
valerian, recommended by Dr. Eberle, or, according to Dr. Condie, the 
spirit of turpentine. If the verminous afl^ection coexist with any of the 
acute local inflammations of the thorax, the former ought to be, as a gen- 
eral rule, neglected, until the latter has been relieved by appropriate treat- 
ment. In doubtful cases, in which it is impossible to ascertain with cer- 
tainty whether the symptoms depend on worms, or upon a simple dyspeptic 
condition of the digestive organs, it is most prudent to give only the sim- 
plest and least irritating vermifuges, to regulate the hygienic conditions of 
the patient, and afterwards to resort to tonics, if necessary. 

Various writers, and particularly M. Guersant, advise that we should 
fori^id, in verminous cases, the use of relaxing food, especially of milk 
preparations, fruits, and of fatty and farinaceous substances ; and that, 
after the expulsion of the worms, we should direct a tonic and strengthening 
regimen. The diet should consist of boiled and roasted meats, of wine, 
and of bitters. The author just quoted, states that a change of food alone 
will often suffice to procure the expulsion of worms. He says {Did. de 
Med., t. XXX, p. 689), " I have met with children who had been tormented 
with ascarides lumbricoides while residing in the country and living upon 
milk and fruits, and who, upon being brought to the city, and put upon 
the use of broths and soups, passed considerable quantities of worms, and 
after that got entirely rid of them." 

Occasionally our opinion is asked with reference to worms of other va- 
rieties, which are reported to have been passed from the rectum of children. 
Thus, tapering elongated pieces of coagulated casein may be mistaken for 
worms. 

So, too, we have seen a specimen, submitted to us by Dr. Bussey, of 
Buena Vista, Texas, and said to have been passed by a boy there, of male 
Gordicus aquaticus, or horse-hair worm. This is a nematoid worm, of 
chestnut-brown color, a foot in length, a little more than one-half line in 
breadth, with a bifid caudal extremity. It grows in stagnant water, and 
thus may readily have been swallowed and passed per anum. 



ASCARIS VERMICULARIS. 981 

ARTICLE II. 

ASCARIS VERMICULARIS. 

The description of this worm has already been given at page 966. 

Seat. — The ascaris vermicularis is found almost exclusively in the large 
intestine, and in a large majority of the cases is confined to the rectum. 
It is said to have been found in the vagina in the female, having no doubt 
passed from the rectum into that canal. 

The causes which determine the presence of this worm are not at all 
understood. 

Symptoms. — The characteristic, and often the only symptom indicative 
of their presence, is violent itching about the anus, which is sometimes 
almost insupportable, and which is generally most troublesome and most 
apt to occur at night when the child is in bed. In consequence of this, 
the sleep is much disturbed, and the child grows peevish and irritable, and 
may suffer considerable impairment of general health. In some instances 
they give rise to acute and violent pain in the region of the anus, and 
sometimes to tenesmus and mucous or bloody stools. When the last- 
named severe symptoms exist, the worms may occasion dangerous nervous 
disorders, and even give rise to general convulsions. The worms not un- 
frequently escape from the rectum and are found upon the bed-clothes, or 
upon the clothes which the child has worn through the day. Sometimes 
they are discharged in considerable numbers, and are found, in that case, 
either mixed with the faeces, or with mucus, or collected into balls or knots. 

The diagnosis of the seat-worm, like that of the lumbricoides, cannot 
be regarded as positive, unless some have been expelled, or unless they 
can be seen by examination of the rectum. This can generally be done 
when they are present in any number, by pressing the nates apart so as 
to open the anus and bring the folds of the mucous coat of the bowel into 
view. The only other symptom which indicates their presence with any 
certainty, is the existence of severe itching about the anus, not to be ex- 
plained upon any more reasonable supposition. 

, Prognosis. — These worms do not, as a general rule, produce the same 
disturbances of the general health as lumbricoides, and in not a few in- 
stances are entirely innocuous, with the exception of the pain^ an-d incon- 
venience they occasion. 

They are, however, exceedingly troublesome, because of the difficulty of 
removing them entirely by any treatment. No matter how many are 
discharged, some almost always remain concealed in the folds of the 
mucous membrane, and as they are propagated with great rapidity, the 
same train of symptoms is very apt to return soon after they may have 
been seemingly dislodged. 

Treatment. — It has been found by long experience that the common 
vermifuges, given by the mouth, exert much less influence in causing the 
expulsion of these worms than of the lumbricoides. For this reason 



982 



ASCARIS VERMICULARIS. 



enemata are generally resorted to in the treatment, instead of remedies 
given by the mouth. Dr. Dewees, however, recommends the elixir pro- 
prietatis (tinct. aloes et myrrhse), in small and often-repeated doses, con- 
tinued for some time, and followed by enemata of lime-water, camphor, 
or aloes. He gave twenty drops of the elixir three times a day, in a little 
sweetened milk, to children from two to four years old, and thirty drops 
to those between five and seven years. 

The plan we have generally resorted to has been to give small doses of 
the wormseed oil, as directed in the article on lumbricoides, and to direct, 
an injection of from four to six grains of powdered aloes, suspended in a 
gill of warm milk, for children four years old, to be repeated once in 
three, four or five days, according to the necessity of the case. 

Lime-water by injection is recommended by several different authorities. 
It may be given of its ordinary strength, or mixed with an equal quantity 
of warm milk, or flaxseed mucilage. Other enemata recommended are 
spirit of turpentine in milk, a teaspoonful of the former to a gill of the 
latter ; decoction of helminthocorton ; an injection made by infusing two 
drachms of fresh garlic-cloves in three ounces and a half of boiling water, 
and adding to the infusion, after it has been poured off, a scruple of assa- 
foetida rubbed up with the yolk of an egg ; a solution of from six to twelve 
grains of sulphuret of potassium in half a pint of water ; injections of sweet 
oil, or of lard beaten up with water until it becomes fluid, and even of 
cold water. The three last-mentioned substances have the advantage of 
calming the itching and irritation of the rectum almost immediately. 
Enemata of a solution of nitrate of silver, in the proportion of two to four 
grains to the ounce of water, have been recommended by Schultz (Deutsche 
Klinik, quoted in Med. Times and Gaz., 1858), who asserts that two, or at 
most three, of these injections suffice to effect a cure. Again, it has been 
recommended to pass a bougie smeared with mercurial ointment into the 
rectum. We should much prefer a method of using this ointment which 
succeeded in the hands of M. Cruveilhier in a very severe case. This was 
to place a little of the ointment on the auus, by which course the patient 
was entirely relieved after a few days. In a very obstinate case in an 
adult, we succeeded in entirely destroying the worms by the daily use of 
suppositories, made unusually long, and impregnated with carbolic acid. 
M. Valleix states that he has obtained the same results by causing the 
anus to be anointed with the following preparation, a small quantity of 
which was introduced at the same time into the inferior extremity of the 
intestine : 

R.— Hydrarg. Chlor. Mitis, .... ^iv. 

Axung., ^vj. — M. 



Dr. Wood states that a dose of sulphur taken every morning before 
breakfast has been found very useful. 

The diet and general health ought always to be strictly inquired after, 
and attended to by the physician. For information upon these points the 
reader is referred to the remarks upon hygienic treatment in the last 
article. 



INDEX. 



Abdomen, examination of, and signs from, 
45, 46 
condition of in enterocolitis, 398 
in cholera infantum, 425 
in tuberculous peritonitis, 850 
in tuberculosis of mesenteric glands, 

852 
in variola, 789 
in typhoid fever, 83n, 833 
in cases of worms, 972 
Abscess of leg, simulating rheumatism, 32 
of lung following pneumonia, 164 
bronchial, in bronchitis, 194 
retropharyngeal, 351 
iliac, in disease of coecum and appendix, 

447, 451 
following erysipelas, 891 
Absorbents in enterocolitis, 405 
Acarus scabiei, description of, 923 
Achorion Schoenleinii, the fungus of favus, 

944 
Acids in local treatment of gangrene of the 
mouth, 314 
carbolic, in gangrene of the mouth, 314 
in diphtheria, 679 
in scabies, 927 
in favus, 952 
muriatic, in gangrene of the mouth, 314. 
in diphtheria, 679 
in typhoid fever, 840 
sulphuric, in chronic entero-colitis, 414 
-^gophony in pleurisy, 229 
Affusion, cold, in scarlatina, 748 

warm, in mild cases of scarlatina, 746 
Air, as injection in intussusception, 469 
Albuminoid degeneration of viscera in scrof- 
ula, 845 
Albuminuria, in pneumonia, 174 
in diphtheria, 671 

during desquamation in scarlatina, 713 
in scarlatinous dropsy, 730 
in variola, 794 
in typhoid fever, 831 
in scrofula, 845 
Alkalies in membranous croup, 102 
in thrush, 340 
in rheumatism, 648 
local use of in diphtheria, 680 

in skin diseases, 952, 956, 960 

Alopecia Areata. 
article on, 958 
frequency of, 958 

fungous nature of, doubtful, 943, 959 
contagion as cause of, 958 
symptoms of, 959 
condition of hairs in, 959 
baldness following, 959 



Alopecia areata, diagnosis of, 959 

prognosis in, 959 

treatment of, 959 
Alum, as an emetic in true croup, 99 

in hooping-cough, 268 
Amaurosis, after diphtheria, 675 

Anesthetics. 

use of during tracheotomy, 119 
in eclampsia, 548 
in tetanus, 582 
Analysis of cow's milk, 330 
of human milk, 338 
of fluid in hydrocephalus, 523 
of bones in rickets, 872 
of fluid in sclerema, 962 

Anatomical Lesions. 
in coryza, 52 

in simple spasmodic laryngitis, 69 
in pseudo-membranous laryngitis, 88 
in congenital atelectasis, 130 
in collapse of the lung, 141 
in pneumonia, 156 
in bronchitis, 193 
in emphysema, 213 
in pleurisy, 227 
in pneumothorax, 248 
in hooping cough, 258 
in cyanosis, 276 
in acute pericarditis, 285 

endocarditis, 287 
in chronic valvular diseases, 288 
in gangrene of the mouth, 305 
in thrush, 317 

in chronic enlargement of tonsils, 344 
in simple pharyngitis, 347 
in simple diarrhoea, 366 
in gastritis, 375 
in entero-colitis, 387 
in cholera infantum, 420 
in dysentery, 437 

in diseases of coecum and appendix, 446 
in intussusception, 457 
in tubercular meningitis, 475 
in simple meningitis, 504 
in cerebral haemorrhage, 515 
in chronic hydrocephalus, 522 
in eclampsia, 540 
in laryngismus, 553 
in tetanus nascentium, 578 
in chorea, 588 

in atrophic infantile paralysis, 617 
in progressive paralysis, with apparent 

hypertrophy of muscles, 637 
in diphtheria, 656 
in mumps, 686 
in rickets, 871 



984 



INDEX. 



Anatomical lesions in albuminoid degenera- 
tion of viscera, 844 
in bronchial phthisis, 849 
in pulmonary phthisis, 849 
in tuberculous peritonitis, 850 
in tuberculosis of mesenteric glands, 851 
in congenital syphilis, 880 
in scarlatinous dropsy, 730 
in scarlatina, 736 
in measles, 778 
in typhoid fever, 828 
in sclerema, 962 
in ascaris lumbricoides, 970 

Anderson McCall. 

on parasitic skin diseases, 945 

Angina ; spe Pharyngitis and Tonsillitis. 

in diphtheria, 662 

in scarlatina, 721, 758 
Antimony in catarrhal croup, 80 

in pseudo-membranous laryngitis, 99 

in pneumonia, 183 

in capillary bronchitis, 208 

excessive action of, in children, 183, 208 

in pleurisy, 237 
Antiseptic remedies in scarlatina, 764 
Antispasmodics in eclampsia, 547 

in laryngismus stridulus, 563 

in tetanus, 583 

in chorea, 602 

Aphtha ; see Follicular Stomatitis. 

fatty nature of deposit in, 298 
Apoplexy ; see. Cerebral haemorrhage, 513 
Apparatus, mechanical, in infantile paralysis, 
624 

Appendix C(eci. 

catarrhal inflammation of, 449 
perforative ulceration of, 451 
article on diseases of coecum and appen- 
dix, 441, 455 

age as cause, 443 

sex as cause, 444 

intestinal concretions as cause, 444 

anatomical lesions of, 446 

cases of, 447 

symptoms of, 449 

duration of, 451 

prognosis in, 452 

diagnosis of, 452 

treatment of, 453 
Arsenic in chorea, 603 
in scrofula, 847 
in eezematous affections, 912 
Artificial food for children, 331 
as cause of indigestion, 354 

Ascaris Lumbricoides. 
article on, 969. 979 
description of, 965 
synonyms of, 965 
early age as cause of, 969 
disposition to, hereditary, 969 
seat of. 969 
number of, 969 
anatomical lesions in, 970 
condition of mucous membrane in, 970 
perforation of intestine by, 970 
haemorrhage from bowel in, 970 
verminous abscesses in, 971 
no diagnostic symptoms of, 971 



Ascaris lumbricoides, digestive disturbances 
caused by, 972 

restlessness caused by, 974 

peculiar physiognomy, caused by, 972 

mechanical effects of, 973 

effects caused by displacement or migra- 
tion of, 973 

dyspnoea and cough caused by, 974 

nervous symptoms caused by, 974 

diagnosis of 975 

prognosis in, 975 

treatment of, 976 

caution in use of vermifuges, 976 

wormseed oil in cases of, 976 

pinkroot in cases of, 977 

turpentine in cases of, 977 

calomel in cases of, 978 

santonin in cases of, 979 

kameela in cases of, 979 

general treatment in cases of, 979 

treatment of complications in cases of,980 

diet in cases of, 980 



Ascaris Vermicularis. 
article on, 981 
description of. 966 
synonyms of, 966 
seat of, 981 
causes of, 981 
symptoms of, 981 
diagnosis of, 981 
prognosis in, 981 
treatment of, 981 
enemata in treatment of, 981 
ointments in treatment of, 982 
Assafoetida in chorea, 602 
Astringents in entero-colitis, 412 

local use of, in diphtheria, 679 
Ataxia, locomotor, after diphtheria, 677 
Atelectasis puimonum, and collapse of the 
lung, 130, 152 
peculiarity of respiration in, 40, 132 
forms of, 130 
congenital, anatomical appearances 

in, 130 
congenital, causes, 131 

symptoms of, 132 
in early weeks of life, symptoms of 

{see Collapse), 133 
diagnosis of, 136 
prognosis in, 136 
treatment of, 137, 150 
effects of position in, 137 
post-natal (see Collapse of lung), 139 
as cause of sclerema, 960 
Atmospheric pressure as cause of deformities 

in rickets, 869 
Atrophy, muscular {see Infantile paralysis), 
609 

Auscultation. 
of heart, 36 
of lungs, 41, 42, 43 

best position of child in, 42 
in true croup, negative results of, 96, 112 
in pneumonia, 175 
in bronchitis, 201 
in pleurisy. 228, 2.34 
of heart in chorea, 589 
in bronchial phthisis, 854 
in pulmonary phthisis, 856 
of head in rickets, 866 



INDEX. 



985 



Barthez. 

results of expectant treatment in pneu- 
monia, 181 

Baths. 

in treatment of cholera infantum, 435 
in treatment of skin diseases, 923, 937 
rold, as prophylactic in catarrhal' croup, 
83 
in treatment of chorea, 605 
in griive c.ises of scarlatina, 746 
hot, in treatment of scarlatinous dropsy, 

762 
in treatment of tetanus, 583 
■tvurm, in treatment of catarrhal croup, 
79, 81 
in eclampsia, 546 
in tetanus, 585 

in mild cases of scarlatina, 746 
in rubeola, 785 
in variola, 804 
Becquerel, pulse in children, 34 
Belladonna in catarrhal croup, 81 
in hooping-cough, 270 
in tetanus, 583 
in infnntile panilysis, 623 
as a prophylnctic in scarlatina, 749 
Benedict, case of laryngismus stridulus, 565 
Bennett J. Hughes, restorative treatment of 
pneumonia, 183 
on bleeding in treatment of pneumo- 
nia, 183 
Berg, fungous nature of thrush, 320 
Billard, pulse in children, 33 
Bird, Golding, alum in hooping-cough, 268 
Bismuth, subnitrate of, in entero-colitis, 406 
Blebs (.wBullEe), 128 

Bleeding in severe spasmodic simple laryn 
gitis, 180 
in pseudo-membranous laryngitis, 97 
in pneumonia, 183 
in bronchitis," 207 
in pleurisy, 237 
in hooping cough, 265 
in gastritis, 379 
in typhlitis. 454 
in intussusception. 468 
in tubercular meningitis, 494 
in simple meningitis, 508 
in eclampsia, 545 
in tetanus, 582 

in atrophic infantile paralysis, 622 
in dropsy following scarlatina, 748 
in rubeola. 783 
Blisters, mode of using in children, 186 
in pneumonia, 186 
in pleurisy, 239 
Blood, condition of, in scarlatina, 737 
in measles, 778 
in variola, 798 
in typhoid fever, 828 
Bloodvessels of skin in sclerema, 963 
Bloody stools in intussuception, 467 
Bones, alterations of, in ricttets. 867 

disease of, in congenital syphilis, 879 
Bothriocephalus latus, 967 
Bouchut, pulse in children, 34 

expectoration in pneumonia, 171 
stools in entero-colitis, 394 
Brain, condition of, in tubercular meningitis, 
477 
in simple meningitis, 504 



I Brain, congestion of {see Cerebral congestion), 
510 
condition of, in cerebral haemorrhage, 515 
in tetanus, 578 
in chorea, 540 
in congenital syphilis, 880 
in scarlatina, 736 
in typhoid fever, 828 
Bretonneau, on nasal diphtheria, 655 

Bronthia. 

dilatation of. in capillary bronchitis, 194 
in chronic bronchitis, 201 
physical signs of, 204 
Bronchial abscess, in bronchitis, 194 
glands, tuberculosis of, 849, 853 
phthisis {see Tuberculosis of bronchial 
glands). 
Bronchitis, connection of, with atelectasis, 
141 
in typhoid fever, 835 
in hooping-cough, 260 
in measles. 774 
in scrofula, 844 

frequency and mortality of, 137-150 
effect of temperature and season upon 
I mortality of, 191 

1 article on, 190 

definition of, 190 
I synonyms of, 190 

I forms'of, 191 

I predisposing causes of. age, sex, season, 

I insufficient clothing, 191 

i exciting causes, 191 

I anatomical alterations in, 193 

; in acute ordinary form, 193 

i in capillary form. 193 

dilatation of bronchia in, 194 
bronchial abscess in, 194 
condition of lung tissue in, 195 
lesions in chronic form. 196 
symptoms of simple acute form, 196 
aggravation of symptoms at night, 196 
duration of simple acute form, 197 
danger of collapse of lung in, 198 
symptoms of capillary form, 198 
duration of capillary form. 200 
symptoms and course of chronic form, 200 
physical signs in, 201 
cough in, 202 

sputa in capillary form of, 202 
peculiar cough in capillary form, 202 
respiration and pulse in, 202 
temperature in, 202 
expression in, 203 
urine in, 203 
diagnosis of, 203 
peculiarity of dyspnoea in, 204 
prognosis in, 205 
treatment of. 205 

importance of confinement to bed, 205 
bleeding in, 207 
emetics in, 208 

antimony in the capillary form, 208 
ipecacuanha in, 209 
external applications, cups in, 208 
use of stimulants in, 210 
use of quinia in, 210 
treatment of chronic form, 211 
Bullae, chapter on, 928 

Cachectic Diseases, 842 



986 



INDEX. 



Calomel (see Mercury), use in spasmodic 
croup, 79 
in membranous croup, 100 
use in diarrhoea, 403 

cholera infantum, 436 
tubercular raeningiti?, 499 
simple meningitis, 509 
chronic hydrocephalus, 529 
eczematous affections, 913 
as a vermifuge, 978 
Cannabis Indica in tetanus, 583 

Canula for Tracheotomy. 

details of size and form, 116 
Capillary bronchitis (see Bronchitis), 193 

Carbolic Acid; see Acid. 
Carpo-pedal spasms, 569 

in laryngismus stridulus, 558 

Cases, Illustrative. 

of chronic coryza, 59 

of pseudo-membranous laryngitis, 124 

of collapse of the lung, 14 7 

of cerebral pneumonia, 174 

of general emphysema, 216 

of chronic emphysema, 221 

of pneumothorax, 250 

of chronic pleurisy, 246 

of cyanosis, 278, 283 

of cardiac disease, 292 

of perforation of appendix coeci, 447 

of tubercular meningitis, 479 

apparent recovery from, 491, 501 

of cerebral haemorrhage, 518 

of laryngismus stridulus, 564-567 

of contraction with rigidity, 571 

of atrophic infantile paralysis, 613 

of progressive muscular sclerosis, 632 

of heart-clot in diphtheria, 673 

of paralysis following diphtheria, 675 

of mode of invasion of scarlatina, 714, 
718 

of grave form of scarlatina, 723 

of croup in, 727 

of convulsions in, 742 

of use of cold lotions in, 751-754 

of Ui-e of ice in angina of, 759 

of convulsions in measles, 768 

of fatal serous effusion in, 777 

fatiil, of measles, 780 

illustrative of protective power of vacci- 
nation, 814 

of tinea, 957 
Catarrh of stomach and intestines (see Indi- 
gestion), 353 

of stomach, 375 

in measles, 767 
Cauterization of variolous pock to prevent 
pitting, 806 

in treatment of diphtheria, 678 
Cavities, tuberculous, 850 

Cerebral Congestion, article on, 510-513 

symptoms of, 511 

duration of. 512 

treatment of, 512 
Cerebral disease in congenital syphilis, 880 
Cerebral form of pneumonia, 176 
Cerebral haemorrhage, article on, 513—521 

definition and frequency, 513 

forms of, cerebral and meningeal, 513 

causes of, 514 



Cerebral haemorrhage, anatomical lesions of, 
515 
of the meningeal form, 515 

transformation of the clot in, and forma- 
tion of pseudo-cyst, 516 

symptoms of cerebral form, 517 

case of, 518 

meningeal form, 518 

chronic hydrocephalus following menin- 
geal form, 519 

duration of, 519 

diagnosis of cerebral form, 520 

meningeal form, 520 

prognosis in, 520 

treatment of, 520 

depletion in, 520 

cold and counter-irritation in, 521 

treatment of paralysis following, 521 

chronic hydrocephalus following, 521 
Cerebral synlptoms, in pneumonia, 173 

in cholera infantum, 426 

in intussusception, 464 

in tubercular meningitis, 480, 484 

in simple meningitis, 505 

in cerebral congestion, 511 

in cerebral haemorrhage, 517 

in chronic hydrocephalus, 526 

in laryngismus stridulus, 557 

in contraction with rigidity, 569 

in chorea, 594 

absence of in atrophic infantile paralysis, 
611 

in mumps, 688 

in scarlatina, 715 

in measles, 776, 786 

in variola, 794 

in typhoid fever, 829, 831, 835. 839 

caused by worms, 974, 981 
Chambers, T. K., on poultices in pneumonia, 
187 

on calomel in diarrhoea, 404 
Chemical characters of false membr.anes, 658 
Chenopodium, oil of, in treatment of worms, 

976, 982 
Chicken pox ; see Varicella. 
Chloral in tetanus, 580 
Chloroform in eclampsia, 548 

in laryngismus, 664 

Cholera Infantum, article on, 416-436 
general remarks on, 416 
definition and synonyms of, 416 
frequency of, 416 
causes of, 417 

great heat as a cause of, 417 
improper diet as a cause of, 418 
hygienic conditions favorable to, 419 
anatomical appearances and pathology of, 

420 
symptoms of, 424 
character of stools in, 425 

of vomiting in, 425 
course and duration of, 426 
diagnosis of, 427 
prognosis in, 427 
prophylactic treatment in, 428 
treatment of stage of evacuation, 429 
of stage of collapse, 431 

Cholera infantum, treatment of, importance of 
free supply of water in, 432 
mistura indica in, 433 
importance of rest in, 433 
treatment of stage of reaction, 434 



INDEX. 



987 



Cholera infnntum, importance of attending to 
state of gums in, 435 
use of baths in, 435 
use of calomel in, 436 

Chorea, article on, 584-609 

definition and synonyms of, 584 
frequency of, 584. 599 
early age as predisposing cause of, 584 
other predisposing causes of, 584 
rheumatism as cause of, 586 
feur and other exciting causes of, 588 
anatomical lesions in, 588 
lesions of heart in, 589 
brain in, 590 
spinal cord in, 591 
microscopical changes in spinal cord in, 

591 
portions of body affected in, 591 
prodromic symptoms of, 592 
symptoms of invasion of, 592 

of the confirmed disease, 592 
respiratory muscles and heart at times 

affected*. 593 
paralysis of sphincters in, 594 
loss of voluntary power in, 593, 611 
general symptoms in, 594 
condition of urine in, 594 
cardiac murmurs in, 594 
course of, 594 
effects of acute intercurrent disease upon, 

595 
duration of, 595 
frequency of relapses, 595 
nature of, 595 

probable seat of lesion in, 596 
alterations of blood as cause of, 597 
reflex irritation as cause of, 597 
embolism as cause of, 287, 598 
mode of action of rheumatism as caus 

of, 599 
prognosis in, 599 
statistics of mortality in, 600 
diagnosis of, 599 
unfavorable symptoms in, 600 
duration of, 600 
treatment of, 601 
use of purgatives in, 601 
antispasmodics in, 602 
cimicifuga in. 602 
arsenic in, 603 
strychnia in, 604 
conium in, 604 
stimuli in, 605 
baths in, 605 

gymnastic exercises in. 606 
Bouchut on treatment of, 604 
hygienic treatment of, 608 
Chronic bronchitis, 200 

pleurisy, 233 
Cimicifuga racemosa in chorea, 602 
Circulatory organs, diseases of. 276 
Clark, J. L., state of spinal cord in tetanus 
579 
in chorea. 591 
Clinical examination of children. 17 
Club-foot in infantile paralysis, 625 
Cod-liver oil in habitual indigestion, 362 
in rickets, 875 
in tuberculosis, 862 
Cod-liver oil in congenital syphilis, 881 
in eczematous affections, 913 



Coecum and appendix coeci, article on diseases 
of, 441-445 
{Sae also Typhlitis, Perityphlitis, and Ap- 
pendix.) 
synonyms and definition of, 441 
seat and character of, 442 
causes of, 443 
intestinal concretions and f-^reign bodies 

as causes of, 444 
anatomical lesions in, 446 
illustrative cases of, 447 
symptoms of, 449 
duration of. 451 
prognosis in, 452 
diagnosis of 452 
treatment of, 453 
typhlitis, 449 
perforation of coecum, 450 
perforative ulceration of appendix, 451 
perityphlitis. 451 
Coecum, symptoms of fecal distension of, 449 
perforative ulceration of, 451 
inflammation of {see Typhlitis). 
Cold, as cause of dropsy after scarlatina, 729 
applications in tubercular meningitis, 497 
in simple meningitis, 509 
in eclampsia, 546 
in laryngismus stridulus, 564 
in tetanus, 583 
in scarlatina, 748 

Collapse op Lung. 

in bronchitis, 195, 197, 202 

in hooping-cough, 259 

in rickets, 872 

article on, 130-152 

in early weeks of life, symptoms of, 133 

cyanofis in. 134 

cases of, 134, 135 

diagnosis of, 136 

prognosis in, 136 

treatment of, 137 

of post-natal atelectasis, 139-152 

general remarks on the pathology of, 139- 
144 

identity of lobular pneumonia with, 141 

anatomical lesions in, 141 

congestion of lung accompanying, 142 

differences between condition of lung in, 
and in pneumonia, 142 

portions of lung affected in, 143 

causes of, and explanation of mode of pro- 
duction, 144 

symptoms of, 146 

•diagnosis of, 149 

prognosis in, 150 

treatment of, 150 

use of emetics in, 151 

treatment of, when combined with bron- 
chitis, 151 
Coloration of skin, significance ofchanges of, 22 

in infants, 30 

of face in pneumonia, 172 

in tubercular meningitis, 483 
Colostrum corpuscles, 339 
Compression of head in hydrocephalus, 530 
Concretions, intestinal, 444 
Condensed milk, 333 

analysis of, 323 

adul'teration of, 337 
Condylomata in congenital syphilis, 878 

Congenital Syphilis : see Syphilis. 



988 



INDEX. 



Congestion of the brain (see Cerebral Conges- 
tion), 510 
Congestion of the lungs, not inflammatory, 
158 
in bronchitis, 195 
in typhoid fever, 835 
Conium in tetanus, 583 

in chorea, 604 
Constipation, as cause of diseases of the coe- 
cura, 444 
in intussusception, 462 
in tubercular meningitis, 481 
Constitutional diseases, 645 
Contagion of hooping-cough, 255 
of diphtheria, 653 
of mumps, 685 
of scarlatina, 705 
of rubeola, 765 
of small-pox, 788 
of varicella, 824 
of typhoid fever, 827 
of favus, 946 
of tinea, 953 
of alopecia areata. 959 
Contraction, with rigidity, article on, 567-577 
a rare affection, 567 
definition of, 567 
causes of, 568 

nature of, one of the forms of eclamp- 
sia, 568 
symptoms of, 568 
carpo-pedal spasms in, 569 
diagnosis of, from symptomatic con- 
traction, 570 
prognosis in. 570 
treatment of, 570 
case by Dr. J. F. Meigs, 571 
Contracture ; see Contraction. 

Convulsions, General, or Eclampsia, article 
on, 532-550 

general remarks on ; forms of, 532 

definition, synonyms, frequency, 532 

predisposing causes of, 533 

most frequent before age of seven 
years, 533 

nervous temperament as a predispos- 
ing cause of, 533 

hereditary nature of, 534 

exciting causes of, 535 

frequency of different forms of, 535 

prodromic symptoms of, 536 

symptoms of the attack, 537 
partial, varieties of, 538 
general, duration of, 538 

nature of, 539 

M. Hall's views on spasm of the lar- 
ynx, 539 

centric and eccentric causes of, 541 

no lesion as yet detected in, 541 

diagnosis of from epilepsy, 541 
the form of convulsion, 542 

prognosis in, 543 

treatment of, 544 

importance of discovering cause of 
attack, 545, 549 

treatment of attack, 545 

bleeding in, 545 

emetics in, 546 

antispasmodics and opium in, 547, 
548 

chloroform in, 548 
internal definition of, 558 



Convulsions, internal, symptoms of paroxysm, 
559 
degree of laryngismus present, 559 
incomplete, or holding-breath spells, 

559 
rarely dangerous, 560 
in pneumonia, 174 
in hooping-cough, 258 
in tubercular meningitis, 483 
in simple meningitis, 505 
in meningeal apoplexy, 518 
in scarlatina, 717, 742 
uraeraic, in scarlatina, 733 
in initial stage of measles, 767 
in later stages of measles, 777, 781, 785 
in typhoid fever, 832, 835 
in worms, 974, 981 
Corson, cold affusions in scarlatina, 750 
Coryza, definition, synonyms, forms, fre- 
quency, 51 
causes of, 51 
anatomical lesions in, 52 
symptoms of mild form, 52 

of severe form, 53 
epistaxis in, 54 
duration of, 54 
prognosis in, 54 

in the course of other diseases, 54 
chronic, symptoms and duration of, 55 
treatment of acute, 56 
local, of acute, 56 
of chronic, 57 
case of chronic, 59 
in congenital syphilis, 878 
in scarlatina. 722 
Cough, in simple laryngitis, 62 

violent in chronic laryngitis, 63 
in true croup, 92 
in pneumonia, 170 
in pleurisy, 231 
in hooping-cough, 255-257 
in spasmodic simple laryngitis, 70, 72 
in bronchial phthisis, 853 
in pulmonary phthisis, 855 
in measles, 769, 774 
in typhoid fever, 835 
Countenance, alterations of, 21 
Counter irritation in tubercular meningitis, 
496 
in simple meningitis, 509 
in chorea, 606 

in pulmonary complications of measles, 
785 
Country residence, importance of in summer, 
399, 429 
in tuberculosis, 861 
Cowhage as a vermifuge, 978 

Cow-Pox ; see Vaccine Disease. 
Cracked-pot sound in bronchial phthisis, 854 
Cream, proportion of in cow's milk, and mode 
of determining, 326 
in human milk, 338 
Croup, diphtheritic, 663 

relations of to pseudo-membranous laryn- 
gitis, 83, 663 
false, spasmodic, or catarrhal (see Spas- 
modic simple laryngitis), 67 
true or membranous {see Pseudo-mem- 
branous laryngitis), 83 
secondary, in scarlatina, 726 
tracheotomy in, 103 
Crust, vaccine, characters of, 819 



INDEX. 



989 



Crusta lactea (see Eczema capitis), 905 
Cry, characters of the, 24 

peculiar in meningitis, 482 

alterations of in simple laryngitis, 62 

peculiar in sclerema, 961 
Crystalli ; see Varicella. 
Currie, cold affusions in scarlatina, 748 
Cutaneous diseases, 882 

not transmitted by vaccination, 817 
Cutaneous diphtheria, 665 

surface, signs from, 22. 30 

Cyanosis, in collapse of the lung, 134 
article on, 276-284 
definition of, 276 
anatomical appearances in, 276 
illustrated cases of, 279, 283 
theories of mode of production of, 280 
symptoms of, 280 

date of appearance of lividity, 281 
modes of death in, 282 
duration of life in, 282 
treatment of the form due to atelectasis, 
283 
of paroxysms of dyspnoea, 283 
hygienic treatment, 283 
eflfect of position on. 284 
neonatorum-, Prof. Meigs on treatment of, 
137 

Cynanche Parotidea ; sef Mumps. 
Cynanche maligna {see Diphtheria). 651 

tonsillaris {see Tonsillitis), 342 
Cyst, pseudo-, in arachnoid, in meningeal ap- 
oplexy, 516 

Deafness after diphtheria, 676 
Decubitis of children, 28 
in different diseases, 29 
in tubercular meningitis, 486 
Deformities in rickets, 867 
Deglutition, diflBculty of in bronchial phthisis, 
853 
in retropharyngeal abscess, 352 
in scarlatina, 721 
Dentition as cause of entro colitis, 386 
of cholera infantum, 4l9 
of eclampsia, 535 
of laryngismus stridulus, 532 
of infantile paralysis, 611 
impeded in rickets, 866 
Desiccation in variola, 793 
Desnos and Huchard on cardiac complications 

in variola, 795, 799 
Desquamation in scarlatina, 712 
in measles, 770 
in small-pox, 793 
in erysipelas, 891 
Development, degree of as aid in diagnosis, 27 

Diagnosis in children, difiBculties of, 18 
general method of, 19 
of simple laryngitis v?ithout spa?m, 64 
of spasmodic simple laryngitis from true 
croup, 74 
from laryngismus stridulus, 560 
of pseudo- membranous laryngitis, 95 
of catarrhal from true croup, 74, 95 
of idiopathic, from diphtheritic croup, 

89, 96 
of atelectasis from pneumonia, and pleu- 
risy, 149 
of collapse of the lung, 149 



Diagnosis of pneumonia from bronchitis, pleu- 
risy, etc., 175-177 

of cerebral pneumonia from cerebral dis- 
ease, 176 

of bronchitis from pneumonia, 203 
from hooping-cough, 203 

of emphysema, 222 

of pleurisy from pneumonia, 235 

in early stage from one of the exan- 
themata, 236 

of pneumothorax, 253 

of hooping-cough from acute laryngitis, 
262 
from tuberculosis of the bronchial 
glands, 262 

of aphthae from ulcero-membranous 
stomatitis, 298 

of ulcerative stomatitis from gangrene 
of the mouth, 309 

of thrush, 323 

of tonsillitis. 343 

of simple pharyngitis. 349 

of retropharyngeal abscess, 352 

of indigestion, 357 

of simple diarrhoea, 369 

of gastritis, 378 

of enterocolitis, 398 

of cholera-infantum, 427 

of dysentery, 438 

of diseases of coecum and appendix, 452 

of intussusception. 465 

of tubercular meningitis, 487 

of simple meningitis, 507 

of cerebral hasmorrhage, 520 

of chronic hydrocephalus, 527 

of eclampsia, 541 

of laryngismus stridulus, 560 

of contraction with rigidity, 570 

of tetanus nascentium, 581 

of chorea, 599 

of atrophic infantile paralysis, 621 

of facial paralysis, 626 

of progressive muscular sclerosis, 635 

of acute rheumatism, 647 

of diphtheria, 670 

of malarial fever, 691 

of mumps, 688 

of rickets, 871 

of tuberculosis, 859 

of tuberculous peritonitis, 860 

of tuberculosis of mesenteric glands, 860 

of congenital syphilis, 880 

of scarlatina, 838 

of rubeola, 740 

of variola, 799 

of vaccine disease, 813 

of varicella, 826 

of typhoid fever, 836 

of scrofula, 845 

of erythema fugax, 883 

of erythema, 885 

of erysipelas, 891 

of roseola, 897 

of urticaria, 901 

of eczeiuatous affections, 910 

of herpes, 922 

of scabies, 925 

of pemphigu-s 929. 932 

of rupia, 932, 934 

of ecthyma, 934 

of strophulus, 937 

of lichen, 938 

of prurigo, 939 



990 



Diagnosis of favus, 949 

of tinea tonsurans, 955 
of tinea circinata, 965 
of alopecia areata, 959 
of sclerema, 962 
of ascaris lumbricoides, 
vermicularis, 981 



INDEX. 



975 



Diaphoretics; seeFonuvhJE. 

hot bath as, in scarlatinous dropsy, 762 
Diarrhoea in thrush, 322 

simple or catarrhal, article on, 364-373 

nature of, 364 

causes of, 364 

improper diet as a cause, 365 

anatomical lesions in, 366 

symptoms of, 367 

course of, 369 

diagnosis of, 369 

prognosis in, 369 

treatment of, 370 

of chronic form, 372 
inflammatory {see Entero-colitis), 380 
in rickets, 866 

in tuberculous peritonitis, 858 
in tuberculosis of mesenteric glands, 860 
in scarlatina, 735 
in measles, 770, 785 
in variola, 806 

in typhoid fever, 829, 833, 839 
Diday^, on infjintile syphilis, 877 
Diet {see also Food), in pneumonia, 189 
after tracheotomy, 123 
in chronic bronchitis, 212 
in pleurisy, 237 
in thrush, 325 

after premature weaning, 325-331 
in indigestion, 361 
improper, as cause of indigestion, 354 

as en use of diarrhoea, 364 
proper in diarrhoea, 370 
in gastritis, 379 
in acute entero-colitis. 401 
in chronic entero-colitis, 409 
improper, as cause of cholera infantum, 

418 
suitable for children, 329, 428 
in tubercular meningitis, 500 
in laryngismus stridulus, 561 
in diphtheria. 683 
in rickets, 874 
in tuberculosis, 862 
in congenital syi.bilis, 881 
in scarlatina, 746, 763 
in rubeola. 782 
in variola, 804 
in typhoid fever, 840 
in scrofula, 846 
in erysipelas, 895 
as cause of urticaria, 899 
in urticaria, 902 
in rupia, 932 
in ecthyma, 935 
in ascaris vermicularis, 980 
Digestive organs, diseases of, 296 

disturbances in early stage of rickets. 866 

in tuberculous peritonitis, 858 

in tuberculosis of mesenteric glands. 

859 
in variola, 794 

in typhoid fever, 829, 830, 832 
in erythema intertrigo, 884, 887 
caused by worms, 972 



Digitalis in scarlatinous dropsy, 763 
Dilatation of bronchia, 194 
Diphtheria, article on, 651-684 

definition and synonyms of, 651 
history of, 651 
statistics of frequency of, 652, 654 
epidemic, contagious, and infectious na- 
ture of, 652 
influence of season upon, 655 
table showing monthly mortality of, 654 
influence of age upon, less than in croup, 

655 
nature of; a constitutional disease, 655 
pathological anatomy of, 656-661 
development of false membranes, 656 
color and consistence of false mem- 
branes, 657 
microscopic anatomy of false mem- 
branes, 658 
chemical characters of false membranes, 

658 
condition of mucous membrane in, 858 
lesions in croup following, 659 
seat of exudation in, 659 
exudation on skin in, 660 
condition of submaxillary glands in, 660 
fatty degeneration of heart in, 660 
condition of kidneys in, 661 
lesions in secondary form, 661 
forms of, 661 
symptoms of, 662 
condition of throat in, 662 
difficulty in deglutition not constant, 663 
danger of exudation extending to larynx, 

663 
symptoms of croup in, 664 
nasal variety of, 665 
cuta.iieo^cs symptoms of, 665 
invasion often insidious, 666 
general symptoms of mild form, 666 

of severe form, 667 
urine in, 668 
eruption in, 668 
course in fatal cases. 668 
malignant symptoms in, 669 
duration of, 669 
prognosis in, 669 
diagnosis of, 670 

from scarlatina, 670 
albuminuria in, 671 
heart-clot in, 672 

Richardson's account of symptoms 
of, 673 

Robinson on, 674 

cases of 673 
endocarditis in, 674 
paralysis following, 674 

order of muscles affected in, 676 

motion and sensation both aflFected, 
676 

result usually favorable, 676 

explanation of, 677 
locomotor ataxia following, 677 
treatment of, 678-684 
local applications to throat in. 678 
solvents for the false membranes, 679 
use of gargles in, 680 
local use of ice in, 681 
external applications in, 681 
injections in nasal form of, 681 
general treatment of. 681 
emetics and purgatives in, 683 
necessity for supporting remedies, 682 



I 



INDEX. 



991 



Diphtheria, stimulants in, 683 
diet in, 684 

necessity for absolute rest, 684 
treatment of the paralysis after, 684 
of heart clots, 684 
Diuretics {ste Formulae), in scarlatinous 

dropsy, 762 
Dress, suitable for children, 82, 400, 429 
Drinks, manner of taking as a diagnostic sign, 

48 
Dropsy, after scarlatina (see article on scar- 
latin;!), 728-785 
treatment of, 760-763 
after measles, 776 
Duchenne, on progressive paralysis, 630 
Dysentery, article on, 436-441 
definition of, 436 
causes of, 437 
anatomical lesions in, 437 
symptoms of, 437 
diagnosis of, 438 
prognosis in, 438 
treatment of, 438 

Earache, violent crying in, 25 
Eclampsia {see Convulsions), 532 
Ecthyma, article on, 933-935 

definition, synonyms, varieties, 933 
causes of, 933 

diagnosis of, from rupia, 932, 934 
prognosis in, 935 
general treatment of, 935 
local treatment of, 935 
vulgure. 

symptoms of, 934 
infantile. 

symptoms of, 934 
Eczematous affections, article on, 903-918 
definition of. 903 
elementary lesions in, 903 
eruption frequently mixed in, 903 
seats of eruption in, 903 
forms of. 903 
causes of, 904 
diagnosis, 910, 926 
prognosis in, 911 
no danger in curing quickly, 911 
principles of treatment of, 911 
general treatment in, 911 
attention to digestive symptoms in, 912 
use of arsenic in, 912 

of cod-liver oil in, 913 
of iron in, 913 
of calomel in. 913 
local treatment of, 914, 918 
cool and emollient applications in. 914 
benzoated oxide of zinc ointment in, 

914 
mode of removing crusts in, 915 
lotions in. 915 
ointments in. 916 
spiritus saponatus kalinus of Hebra in, 

917 
solutions of potash in, 918 
tarry applications in, 917 
use of soaps in. 917 
mercurial applications in, 917 
eczema simplex. 
symptoms of, 904 
diagnosis of from scabies, 626, 910 
from sudamina, 910 
eczema pnpiilosiun. 
symptoms of, 904 



Eczematous affections. 

eczema piistulosum, or imptigijioides, 
symptoms of. 905 
diagnosis from favus, 910 
prognosis in, 911 
eczema capitis. 
symptoms of, 905 
condition of scalp in, 906 
chronic form of. 907 
mode of removing crusts in, 915 
eczema faciei. 

symptoms of, 907 
eczem.a larva le. 

general symptoms in, 908 
duration of, 908 
eczema grannlatuin. 
symptoms of, 909 
eczema, tarsi. 

symptoms of, 909 

treatment of, 918 

impetigo fig urata, 909 

spursa, 909 
eczema chrouicum. 

common to all varieties, 910 
symptoms of, 910 
seats of, 910 
duration of, 910 
general treatment of. 912 
local treatment of, 916 
Electrical batteries, 623 
Electricity in chorea, 606 

in infantile paralysis. 616, 623 
in facial paralysis, 627 
in progressive paralysis, 631, 639 
in diphtheritic paralysis, 684 
Electro-muscular contractility in infantile 
palsy. 613, 616 
in facial palsy, 627 
in progressive palsy, 631 
Embolism in endocarditis as cause of chorea, 

287, 597 
Emetics in catarrhal croup. 78, 80 
in membranous croup, 98 
in collapse of the lung, 151 
in bronchitis, 207 
in hooping-cough, 267 
in eclampsia, 546 
in diphtlleria, 683 
Emphysema, time and cause of existence, 213 
anatomical appearances, 213 
vesicular. 213 
interlobular, 213 
causing pneumothorax, 215 
case of, 215 

causes of age, previous disease, etc., 216 
mecha.-ism of production, 216 
symptoms, rational, 218 
physical signs, 220 
case of, 221 
diagnosis of, 222 
prognosis in, 222 
treatment of, 223 
association with pneumonia, 161 
Empyema, symptoms and course of {see Pleu- 
risy), *233 
paracentesis in, 242 
Empyreumatic oil of Chabert, as a vermifuge, 

979 
Endocarditis, in diphtheria, 674 
in scarl itina, 736 
acute. 286 

symptoms of, 286 
prognosis in, 287 



992 



INDEX. 



Endocarditis, acute, anatomical appearances 
in, 287 

embolism in, in connection with 
chorea, 287 

treatment of, 287 
Enemata, astringent, in chronic entero-coli- 
tis, 413 

in dysentery, 440 
in disease of coecum. 454 
of air and fluids in intussusception, 468 
in echimpsia, 547 
in diphtheria, 683 
in treatment of worms, 981 
Enteritis in measles, 776 
in variola, 793, 806 
Entero-colitis, article on, 380-416 
definition of, 380 
frequency of, 380 
improper food and intense heat as causes 

of, 381 
table of mortality in. 382 
analogies to camp diarrhoea, 385, 390 
dentition and weaning as causes of, 386 
anatomical lesions in, 387 
seat of disease in. 387 
condition of intestinal follicles in, 389 
lesions in chronic form, 390 
microscopic changes in intestines, 391 
condition of stomach in, 392 
of liver in, 392 
of mesenteric and mesocolic glands in, 

392 
pathology of, 392 
symptoms of in acute form, 393 
condition of stools in acute form. 394 

of abdomen in acute form, 395 
vomiting in acute form, 396 
erythema of buttocks in acute form, 396 
duration of acute form, 397 
symptoms of chronic form. 397 
course and duration of chronic form, 397 
diagnosis of, 398 
prognosis in, 398 
treatment of acute form, 398-409 
prophylactic, 398 

necessity for change of residence, 399 
importance of exercise in open air, 400 
diet in, 401 

therapeutical treatment of, 401 
cold water in treatment of, 402 
use of calomel in, 403 
use of opium in, 404 
use of astringents and absorbents in, 405 

of tonics and stimulants in, 407 
remedies for vomiting in, 4ii8 
treatment of chronic form, 409-416 
diet in chronic form, 410 
creasote in, 409, 414 
use of raw meat in chronic form, 410 
nitrate of silver in, 412 
astringent enemata in, 413 
sulphuric acid in, 414 
tonics and stimulants in, 415 
Epidemic nature of diphtheria, 652 

of mump?, 686 

of scarlatina, 706 

of rubeola, 764 

of variola, 787 

of varicella, 824 

of typhoid fever, 827 

of roseola, 896 
Epilation in favus, 951 
in tinea, 956 



Epistaxis in coryza, 55 

in measles, 769 

in bronchial phthisis, 853 

in typhoid fever, 834 
Ergot, in infantile paralysis, 623 
Eruption in diphtheria, 668 

in mild cases of scarlatina, 710 

in grave cases of scarlatina, 719, 722 

in measles, 769 

in malignant measles, 773 

in variola, 790 

in varioloid, 797 

in varicella, 825 

in typhoid fever, 829, 831, 834 

in erythma fugax, 883 
intertrigo. 884 
nodosum, 885 

in erysipel'S, 890 

in roseola, 896, 897 

in urticaria, 899, 90a 

in eczematous affections, 904, 910 

in herpes, 918, 922 

in scabies. 924 

in pemphigus, 928 

in rupia, 931, 932 

in ecthyma, 934, 935 

in strophulus, 936 

in lichen, 938 

in prurigo, 939 

in psoriasis, 941 

in pityriasis, 941 

in ichthyosis, 942 

in favus", 947, 948 

in tinea. 954. 955 
Eruptive fevers, 701 
Erysipeliis, article on, 888-895 

definition and forms of, 888 

frequency of, 888 

causes of, 888 

following vaccination, 889 

epidemic and endemic nature of. 889 

starting-point of eruption, 889 

symptoms of, 889 

characters in very young infants, 890 

sloughing of skin in, 890 

characters of in older children, 890 

desquamation in. 891 

abscesses following, 891 

febrile symptoms in, 891 

typhoid ."yraptoms in, 891 

duration of, 891 

diagnosis of, 891 

prognosis in, 892 

treatment of in young infants, 892 

local applications in, 893 

tr. ferri.'chl. in. 894 

treatment of in older children, 894 

stimulants and tonics in, 895 

local applications in, 895 
Erythma about anus in thrush, 322 

of buttocks in entero-colitis, 396, 884 

article on, 883-888 

definition and forms, 883 
fugax. 

symptoms of, 883 

diagnosis of from scarlatina, 884 
from erysipelas, 885 
from roseola, 886 

intertrigo. 

seat of eruption, 884 
character of eruption, 884 
ulceration in, 884 



INDEX 



993 



Erythema intertrigo, form of occurring in con- 
nection with diarrhoea, 884 

prognosis in, 886 

treatment of, 886 

local applications in, 886 

attention to digestive derangement in, 887 
nodosayii. 

symptoms of, 885 

diagnosis of from phlegmonous erysipelas. 
886 

prognosis in, 886 

treatment of, 887 

tonics and stimulants in, 887 

local appliciitions in, 888 
Essay, introductory, 17 
Essential convulsions {fee Convulsions). 
Essera (s^e Urticaria), 899 
Examination, clinical, in children, 17 

difficulties of, 17, 18, 19 

of abdomen, 45 

of the heart, 35, 36 

of mouth and fauces, 47 

of the pulse. 33, 34, 35 
Exercise in open air, importance of, 400 
Expectoration, nummular, in measles, 770 

in true croup, 93 

in pneumonia. 171 
Expiratory respiration in bronchitis, 202 
External applications {see Local applications). 

Facial paralysis (5.«e Paralysis). 
Facies {see- Physiognomy). 
False membrane, in croup, characters of, 88 
in secondary croup, 89 
extent of and frequency with 
which bronchia are invaded, 88 
action of chemical reagents upon, 679 
in capillary bronchitis, 193 
in diphtheria, 656 
in scarlatina, 720 
Fauces, examination of, 47, 48 
in membranous croup, 89 
in simple pharyngitis, 348 
in diphtheria, 659 
in scarlatimt, 712, 720 
in measles, 768 
Pavus. article on. 946-952 

definition and synonyms, 946 
varieties and frequency of, 946 



Fecal accumulation as cause of eclampsia, 549 
Fevers, eruptive, 693 

scarlet {see Scarlatina), 702 

in variola, subsides on appearance of 

eruption. 792 
secondary in variola, 792 
typhoid, 827 

febrile action in, 832 
Finlayson, normal temperature in children, 38 
Follicles of intestine in entero-oolitis. 389. 391 
Fomites as means of transmitting scarlatina, 
706 
variola, 789 
Food, artificial, 325, 339 
gelatin, for infants, 332 
Merei's for infants, 332 
improper, as eau>e of indigestion, 354 
of diarrhoea, 365 
of entero-colitis, 381 
of laryngismus stridulus, 552 
Foot-baths, in treatment of diseases, 186, 207, 
784 

Formulary of receipts recommended. 

Alteratives. 
Formula for mixture of iodide of potassium 
and bichloride of mercury, 496 
for iodide of potassium and compound 

decoction of sarsaparilhi, 847 
for iodide of potnssium, syrup of 
iodide of iron, and syrup of ginger, 
847 
Antacids avd alkalies ; lax"tives. 
Formula for mixture of soda, rhubarb, and 
paregoric. 341 
of magnesia and tr. thebacic, 341 
of sulphate of magnesia and rhubarb, 

371 
of sulphate of magnesia and lauda- 
num. 371 
of soda, blue mass, and paregoric,402 
of crabs' eyes, 406 
for neutral mixture, 409 
of acetate and bicarb, potash and 
opium, 649 
Antiseptic. 
Formula for mixture of chlorinated lime, 304 
Ai'thrlmintics. 



description ofthe fungus which causes, 944 Formula for mixture of ol. chenopodii, 977 



contagion as cause of, 946 

occurs in lower animals, 946 

other causes of, 947 

symptoms of, 947 

nature of. 949 

diagnosis of, 949 

prognosis in, 950 

general treatment of, 950 

local treatment of, 950 

mode of removing crusts in, 950 

epilation in, 951 

parasiticides in, 951 
dispersiis. 

eruption in. 947 

course of, 947 

condition of hairs in, 947 

baldness following, 948 

seats of the eruption, 948 
conftrtus. 948 

eruption in, 948 
Fecal accumulation in coecum, symptoms of, 
449 
diagnosis of, 466 



of spigelia, magnesia, and manna, 

977 

of ol. terebinth, and magnesia, 978 
of santonin, etc., 978 
A ntispasjnodics. 
Formula for pills of belladonna, opium, and 
valerian, 266 
for mixture of belladonna and opium, 266 
Astritigejits. 
Formula for mixture of alum and honey of 
roses, 297, 342 
of sulphate of copper and cinchona, 

303 
of sulphate of copper and quinia, 351 
for aromatic syrup of galls, 406 
of morph. sulph., and dil. sulph. acid, 

409 
of soda, krameria, and opium, 912 
of nitrate of silver. 413 
solution of nitrate of silver, 413 

of pernitrate of iron and nitric acid, 
414 



63 



994: 



INDEX. 



Formula of aromatic opium and krameria, 
414 
of acetate of lead and acetic acid, 431 
Pfhrif ages and diiiretics [see also Alkalies). 
Formula for mixture of citrate of potash, 
ipecac, and paregoric, 80 
of ipecac, opium, sp. aether, nitrosi, 206 
of morphia, liq ammon. acet., 2!1 
of iodide of potassium and sarsaparilla, 

238 
of squill and digitalis, 239 
of carbonate of potash, antimony, and 
opium, 66 
senega and opium, 66 
of acetate of potash, digitalis, and squill, 

763 
of bitart. of potash, juniper, and sp. 

aetheris nitrosi, 762 , 

of powders of sulphurated aniimony and 
Dover's powder, 80, 184 
of opium, ipecac, and nitrate of pot- 
ash, 247 
Foods. 
Formula for gelatin-food for children, 332 
for Merei's food for children, 333 
for preparation of raw meat, 410 
Laxatives (sf-e also Antacids). 
Formula for mixture of sulphate of soda, sen- 
na, and laudanum, 454 
for pill of opium and colocynth, 454 
of blue pill, castor oil, and aromatic syrup 
of rhubarb, 572 
Local applications. 
Formula for lotion of carbonate of potash and 
sulphur, 916 
of lime and sulphur, 927 
of bichloride of mercury, 916 
of soft soap and alcohol (Hebra'ssp. 
saponatus kalinu?), 917 
for ointment of elder flowers, 923 

of glycerin and ung. aq. ros , 747 
for benzoated oxide of zinc ointment 

(Bell's formula), 914 
for mercurial ointment to prevent pitting 

in variola, 808 
for ointment of nitrate of mercury and 
belladonna, 58 
of protiodide of mercury, 916 
of calomel and camphor, 916 . 
of ammon chl. of mercury with sul- 
phur, 956 
of tar and vin. opii, 917 
of tar and iodine, 956 
of sulphur and carbonate of potash 

(Wilson), 927 
of sulphur and carb. potash (Hel- 
merich). 927 
Nervous sedativfs. 
Formula for mixture of antimony, valerian, 
and paregoric, 67 
of antimony, \ aleiian, and laudanum, 
188 
Nervous stim u la. ?/ ts . 
Formula for mit^tura indica, 433 

Specific remedies. 
Formula for mixture of carbonate of potash 
in hooping-cough, 268 
of alum and conium in hooping- 
cough, 269 
of alum in hooping-cough, 269 

and belladonna in hooping- 
cough, 270 



Tallies. 
Fotmula for mixture of cod-liver oil, 363 
of nux vomica and gentian, 373 
Formula of tr. ferri chl , acetic acid, and sp. 
Mindereri, 415, 495, 758 
of quinia, morphia, and sulph. acid, 

649 
of quinia and dil. sulph. acid, 210 
of elix. cinchona and curacoa, 210 
of arsenic and bitter wine ofiron, 912 
Forster. temperature in new-born children, 37 
Fox, Wilson, on softening of stomach, 377 
on use of cold in treatment of hyper- 
pyrexia, 750 
French measles {see Roseola), 896 
Frequency of diseases {see Statistics). 
Fuller, statistics of tracheotomy, 104 
Fungi in skin diseases {see Parasites). 
Fungous origin of measles, 766 

Gairdner, collapse of the lung, 139 
lesions in bronchitis, 195 
difference between dyspnoea of pneumonia 
and bronchitis, 204 
Galls, aromatic syrup of, 406 
Gangrene, of mouth (s^e Gangrenous stoma- 
titis), 309 
of pharynx in diphtheria, 659 

in scarlatina, 721 
of skin in erysipelas, 891 
Gargles in diphtheria, 680 
Gastritis, article on, 374-379 

frequency and nature of, 374 
causes of, 374 
anatomical lesions in, 375 
softening of stomach in, 376 
symptoms of, 377 
diagnosis of, 378 
prognosis in, 378 
treatment of, 378 
Gastromalacia {see Softening of stomach). 
Gastrotomy in intussusception, 470 
General diseases, introductory remarks upon, 

645 
Gerhard, G. S , on chorea, 585 
Gestures, significance of, 28 
Glands, bronchial, tuberculosis of, 849, 853 
cervical, in scarlatina, 722 
intestinal, in scarlatina, 737 

in typhoid fever, 828 
mesenteric, tuberculosis of, 851, 858 
parotid, in mumps {see Mumps). 

in scarlatina, 722 
submaxillary in diphtheria, 660, 662 • 
enlarged in some cases of mumps, 687 
enlarged in scarlatina, 721 
Glottis, spasm of. in eclampsia, 540 
{fee Laryngismus stridulus), 550 
Golis, on treatment of hydrocephalus, 529 
Gregory, cold aff'usions in scarlatina, 749 
Guersant, mortality of true croup, 88 
Guinier, statistics of paracentesis, 242 
Gum {see Strophulus), 936 
Gummy tumors in congenital syphilis, 880 
Gums, importance of lancing in cholera in- 
fantum, 435 
in laryngismus, 561 
Gutta percha. solution of, to prevent pitting 

in variola. 808 
Gymnastic exercises in chorea, 606 
in infantile paralysis, 624 

Haemoptysis in pulmonary phthisis, 855 



1 



INDEX. 



995 



Hair, in favus, 948. 949 

in tinea,, 954, 955 • 

in alopecia areata, 958 
Hull, Marshiill, on spasm of glottis in eclamp- 
sia, 539 
on nature of laryngismus, 556 
Hammond, electrical condition of muscles in 

infantile paralysis, 616 
Harley, John, on connection of scarlet and 

enteric fevers, 737 
Harris, R. P., on hereditary nature of eclamp- 
sia, 535 
Head, peculiarities of, in hydrocephalus, 525 
in rickets, 868 
soft spots on, in rickets, 867 
Heart, physical examination of, 35, 36 
sounds of, 35 

diseases of, article on, 284-295 
(see Pericarditis and Endocarditis-) 

causes of, 284 
chronic valvular diseases of, 288 
causes of, 288 

anatomical appearances in, 288 
symptoms of aortic disease, 289 

prognosis in, 290 
symptoms of mitral obstruction, 290 

prognosis in, 291 
symptoms of mitral regurgitation, 291 

prognosis in, 291 
compensation for, efifeeted by grow- 
ing heart, 292 
tendency to improve by time, 292 
treatment of, 292 
illustrative cases of, 292 
in chorea, 589 

irregular action of, in chorea, 594 
fatty degeneration of, in diphtheria, 660 
inflammation of endocardium in diph- 
theria, 674 
inflammation of membranes of, in scar- 
latina, 736 
Heart-clot in diphtheria, 672, 684 

in scarlatina, 738 
Heat, intense, as cause of entero-colitis, 383 
Heat of surface (t^ee Temperature). 
Hebra, on treatment of eczema, 917 
Helminthocorton as a vermifuge, 979 
Hemiplegia in chorea, 594 

in cerebral haemorrhage, 518 
cerebral, diagnosis of, from facial paraly- 
sis, 627 
Hgemorrhage during paroxysms of hooping- 
cough, 256 
intestinal, in intussusception, etc., 466 
in typhoid fever, 835, 840 
Herpes, article on, 918-923 
definition of, 918 
varieties of, 918 
frequency of, 918 
causes of, 918 
diagnosis of, 922 
prognosis in, 922 
general treatment of, 922 
local treatment of, 923 
phlyctef/odes. 

seat of eruption in, 919 
symptoms nf, 919 
diagnosis of from pemphigus, 922 
treatment of, 922 
lab /'alls . 

seat of eruption in, 920 

symptoms of, 920 

local applications in, 923 



Herpes zoster, definition of, 920 

seats of, 920 

character of eruption, 921 

course and duration of, 921 

general symptoms in, 921 

pain in, 921 

diagnosis of, 922 

local applications in, 923 
circinatus (««e Tinea eir-ein{d;a), 955 
iris. 

symptoms of, 921 

seat of, 922 

parasitic nature of, 922 

diagnosis of from roseola annwlata, 922 

treatment of, 922 
Hewitt, Grailly, on collapse of the lung in 

hooping-cough, 259 
Hives (-see Urticaria), 8D9 
Hillier, indications for bleeding in pneumo- 
nia, 181 

on pathology of infantile paralysis, 617 

albuminuria in diphtheria, 672 
Holding-breath spells {<see Convulsions, inter- 
nal), 559 
Hooping-cough, article on, 254-275 

definition, synonyms, frequency, 254 

causes, influence of age, 254 

contagion and epidemic influence, 255 

stages of, 255 

symptoms and duration of first stag«, 
255 
of second stage, 255 

character of paroxysms, 255 

haemorrhages during this stage, 256 

convulsions during this stage, 256 

duration of paroxysms, 257 

number of paroxysms, 257 

symptoms and duration of third stage, 
257 

absence -of general symptoms in, 257 

urin-e in, 257 

total duration of. 257 

convulsions as a complication, 258 

excessive laryngismus as a complication, 
259 

collapse of the lung as a complication. 
259 

bronchitis as a complication, 260 

pneumonia as a complication, 261 

vomiting in, 261 

emphysema as a sequel, 261 

tuberculosis and scrofula as seqaelse, 261 

diagnosis of from acutt catarrh, 262 

from tuberculosis of broncbial 
glands, 262 

prognoMS in, 268 

nature of, 264 

anatomical lesions, 258 

mortality in, 264,^^ 

treatment of simpl^orm, 264 

bloodletting in, 265 

belladonna in, 266 

hydrocyanic acid in, 267 

carbonate of potash in, 268 

alum in, 268 

inhalations in, 270 

local applications in, 271 

treatment of complications of, 272 
of paroxysms of, 274 

hygienic treatment of, 274 
Hunger, crying from, 25 

Hunt, S. B., change of residence in chronic 
diarrhoea, 399 



996 



INDEX. 



Hutchinson, J., on transmission of syphilis 
by vaccination, 818 
alteration of teeth in congenital 
syphilis, 879 
Hydrencephalic cry, 482 

Hydrocephalus, acute {see Tubercular menin- 
gitis), 
chronic, following meningeal apoplexy, 
519 
article on, 522-531 
forms of, 522 

anatomical appearances in, 522 
analysis of fluid in, 523 
causes of internal form, 524 

external form, 525 
symptoms of, 525 
enlargement of head in, 525 
cerebral symptoms in, 526 
mode of death in, 527 
diagnosis of from rickets of the skull, 
527 
from hypertrophy of the brain, 
528 
prognosis in, 528 
treatment of, 529 
use of mercury in, 529 
compression of head in, 530 
paracentesis in, 531 
injections into cranial cavity in, 531 
Hydrochloric acid in diphtheria, 678 
Hydrocyanic acid in hooping-cough, 267 
Hygienic conditions, influence of unfavor- 
able, 419 
treatment in chorea, 608 
in measles, 781 
Hypertrophy of tonsils [see Tonsils, chronic 

enlargement of), 344 
Hyposulphites, use of in scarlatina, 756 

Ice, local use of in eclampsia, 548 
in tetanuSj 583 
in diphtheria, 681 
in scarlatina, 755, 759 
in angina of scarlatina, 758 
Ichthyosis, symptoms of, 942 

treatment of, 942 
Ileus (5e« Intussusception). 
Impetigo {see Eczema impetiginoides). 
larvalis (see Eczema larvale), 908 
granulata {see Eczema granulatum), 908 
figurata, 909 
sparsa, 909 
Incubation, of scarlatina, 705 
of measles, 765 
of small-pox, 789 
Indigestion, article on, 353-364 

definition, frequency, forms, 353 

causes of. 354 

symptoms of occasional form, 355, 356 

of habitual form, 356, 357 
diagnosis of, 357 
prognosis in, 358 

treatment of occasional form in infants, 
358 
in older children, 359 
of habitual form, 360 
as cause of eclampsia, 549 
Infantile paralysis {see Paralysis). 609 
Infantile remittent fever {see Typhoid fever). 

syphilis {see Syphilis). 
Inflammation, catarrhal, of larynx, without 
spasm, 61 
with spasm. 67 



Inflammation of larynx with pseudo-mem- 
branous exudation, 83 
of lungs, 153 
of bronchia, 190 
of pleura, 226 
Inflation, effect of on collapsed lung, and in 
atelectasis, 130. 143 
impossible in pneumonic lung, 160 
in congestion of lung, 159 
Inhalations in treatment of membranous 
croup, 102 
of coal gas in hooping-cough, 270 
Injections {see Eneraata). 

into cranial cavity in hydrocephalus, 531 
into pleural sac after paracentesis, 245 
in nasal diphtheria, 681 
of air in intussusception, 468 
Inoculability of scarlatina, 706 
Inspection of thorax in pleurisy, 230 
Inspiration, recession of base of thorax in, 41 
Internal convulsions (see Convulsions and 

Laryngismus). 
Intertrigo {see Erythema), 884 
Intestines, inflammation of, in measles, 775 
and stomach, general remarks upon 
diseases of, 353 
Intussusception, article on, 456-471 

definition, synonyms, and forms, 456 

frequency, 456 

anatomical appearances, 457 

divisions of, 457 
most frequent seat of, 457 
pathology of. 457 
modes of termination of, 458 
case of elimination of the invaginated 

bowel, 460 
causes of, 460 
mode of production, 461 
symptoms of, 461 
duration of, 464 
modes of termination of, 464 
prognosis in, 465 
diagnosis of, 465 
differential diagnosis of, 466 
treatment of, medical, mechanical, and 

surgical, 468-471 
use of purgatives in, 468 
injections of air and fluids in, 468 
hydrostatic pressure in treatment of, 469 
gastrotomy in, 470 
Inunction in scarlatina, 746 

of cod-liver oil in rickets, 875 
in tuberculosis, 862 
Invagination {see Intussusception), 456 
Invasion of diphtheria often insidious, 666 
of mild cases of scarlatina, 709 
of grave cases of scarlatina, 714, 719 
of measles, 766, 771 
Iodide of potassium {see Potassium). 
Iodine, in tubercular meningitis, 495 

as injection in chronic hydrocephalus. 531 
Iron, in laryngismus stridulus, 563 
in infantile paralysis, 623 
in rheumatism, 649 
local use of in'diphtheria, 679 
in tuberculosis, 862 

chloride of, with acetic acid, and sp. Min- 
dereri, 415 
in diphtheria, 682 
in scarlatinous angina, 757 
in erysipelas, 894 
iodide of, in pleurisy, 238 
in chronic eczema, 913 



INDEX. 



997 



Iron, nitrate of, in chronic entero-colitis, 414 

enema of in dysentery, 440 
Itch {see. Scabies), 923 

Jacobi, statistics of tracheotomy in croup in 
New York, lOfi, 114 
local applications in diphtheria, 680 
Jenner, recession of base of shest in inspira- 
tion, 41 
on rickets, 868, 869 
Joints, condition of in rheumatism, 646 
affection of, in scarlatina, 735 

Kameelaas a vermifuge, 979 
Keratitis, in congenital syphilis, 879 
Kidneys, condition of in diphtheria, 661 

in scarlatinous dropsy, 730 
Kine-pock {see Vaccine diseases). 

Laborde, sclerosis of spinal cord in infantile 

palsy, 620 
Lancing gums {sec Gums). 
Laryngismus, exces<ive in hooping-cough, 259 
in eclampsia. 640 
in rickets, 870 
stridulus, article on, 550-567 

definition and synonyms, 550 
frequency of, 550 
predisposing causes of, 551 
nature and exciting causes of, 553 
anatomical appearances in, 553 
enlargement of thymus gland in, 554 
centric and eccentric causes of, 556 
symptoms of paroxysm of, 557 
duration and course of, 558 
danger of sudden death in, 558 
other forms of, 558 
holding-breath spells, 559 
diagnosis of, 560 
prognosis in. 560 
treatment of, 561 
importance of lancing gums in, 561 

attention to diet in, 561 
antispasmodics in, 563 
iron in, 563 

treatment of paroxysm, 564 
change of residence in, 564 
illustrative cases, 564 
Laryngitis, in scarlatina, 725 
in measles, 775 
in small-pox, 792 
chroiuc, 63 
pseiido- meiyihranous, 83 

definition, synonyms of, 83 

nature and relations to dif>htberia, 

83, 84 
frequency of faucial deposit in, 85,89 
frequency of, 86 
mortality from, 86 
predisposing causes of, 87 
exciting causes of, 87 
second attacks of, 88 
anatomical lesions in, 88 
extent and characters of false mem- 
branes, 88 
mucous membrane rarely ulcerated, 

90 
symptoms of, 91 

of irjitial stage, 91 
characters of voice and cough, 91, 92 

of respiration, 92 
explanation of recession of base of 
chest in, 93 



' Laryngitis, expectoration and rejection of 
false membrane in. 93 
negative results of auscultation in, 

93, 112 
mode of recovery in, 94 
duration of, 95 
diagnosis of. 95 
pseudo-niembra7ious, importance of 

examination of throat in, 96 
prognosis in. 96 
treatment of, 96 

bloodletting in, 97 
emetics in, 98 
antimony in, 99 
mercury in. 100 
alkalies in. 101 
opium in, 101 
local treatment in, 101 
inhalations in. 102 
hygienic treatment, 103 
summary of the treatment of, 103 
tracheotomy {see under that head), 
103 
spasmodic, siviple, 67-83 
synonyms of, 68 
forms of, 68 
causes of, 68 
anatomical lesions in, 69 
symptoms of, 70 
duration of, 72 
nature of, 73 
diagnosis of from true croup, 74 

from laryngismus stridulus, 560 
peculiarities of voice in, 75 
prognosis in, 77 
treatment of the mild form of, 78 

of the severe form of, 80 
hygienic treatment of, 81 
prophylactic treatment of, 82 
style of dress suitable in, 82 
simple, without spasm, 61 

definition and frequency of, 61 
causes of, 61 

anatomical lesions in, 61 
symptoms and course of, 62 
duration of, 64 
diagnosis of, 64 
prognosis in, 65 
treatment of, 65 
Larynx, general remarks on diseases of, 59 
Legendre and Bailly, researches on collapse 

of lung, 139 
Lichen, article on, 937, 938 

strophulus {see Strophulus), 936 
tropicus, the variety usually met with, 938 
frequency of, 938 
cause of, 938 
symptoms of, 938 
duration of, 938 
diagnosis of, 938 

of from scabies, 926 
prognosis in, 938 
treatment of. 938 
vrticatus {see Urticaria), 900 
Liebig. food for infants, 338 
Liver, state of in entero-colitis, 392 
in rickets, 872 
in congenital syphilis, 879 
Lobular pneumonia, in reality collapse of 

lung, 139 
Local applications in chronic coryza, 58 
in membranous croup, 101 
in pneumonia, 186 



INDEX. 



Local applications in bronchitis, 208 

in pleurisy, 2H9 

in hooping-cough, 271 

in aphtha?. 299 

in ulcero-membranous stomatitis, 203 

in gangrene of the mouth, 311 

in thrush, 341 

in diseases of ceecum and appendix, 455 

of cold in tubercular meningitis, 497 

of cold in simple meningitis, 508 

in eclampsin, 546, 548 

in chorea, 605 

in rheumatism, 650 

in diphtheria, 678 

in mumps, 688 

in congenital syphilis. 881 

to throat in scarlatina, 746, 758 

external in scarlatina, 746 

in erysipelas, 892, 895 

in eczema, 914 

in herpes, 923 

in scabies, 926 

in pemphigus, 930 

in rupia, 933 

in ecthyma, 935 

in strophulus, 937 

in lichen, 938 

in prurigo, 940 

in psoriasis, 941 

in pityriasis, 942 

in ichthyosis, 942 

in favus, 950 

in tinea. 956 

in erythema intertrigo, 886 

in alopecia areata, 959 
Locomotor ataxia following diphtheria, 677 
Lotions (5ffi Formulae) . 

of water in scarlatina, 948, 951 

in treatment of eczema, 914 
Lumbricus {see Ascaris lumbricoides). 
Lungs, auscultation of, 41, 42, 43 

general remarks on diseases of. 129 

collapse and imperfect expansion of, 130- 
152 

inflpnimation of, 153 

abscess of, following pneumonia, 158 

congestion of, non-inflammatory, 159 

condition of in pleurisy, carnification, 228 

collapse of, in rickets, 872 

tuberculosis of, 849, 855 

percussion of, 43. 44, 45 

condition of, in congenital syphilis, 880 
in typhoid fever, 829, 830, 834 
in sclerema, 963 



Magnesia, hyposulphite of. in scarlatina, 756 
Malarial fever, 689 

causes, frequency of. 689 
symptoms of acute, 689 

features of paroxysm imperfectly de- 
veloped, 690 
of chronic, 691 
enlargement of spleen in, 691 
neuralgia rare in, 691 
diagnosis of, 691 
prognosis in, 691 
treatment of, 692 
quinia in, 692 
iron and arsenic in, 692 
Marsh. F. H., on tracheotomy in croup, 115 
Maturative fever in variola, 792, 804 
Maw-worm (see Ascaris vermicularis). 



Measles {see Rubeola), 764 

French {see Roseola). 
Meigs, Charles D., treatment of coryza, 56 
use of alum as an emetic, 99 
on proper position of body in atelectasis 
and cyanosis, 137, 284 
Meigs, Charles D., treatment of paroxysm of 

laryngismus, 564 
Meigs, J. F., case of contraction with rigidity, 
571 
heart-clot in diphtheria, 673 
Membrane, false {see False membrane). 
Meningeal apoplexy {see Cerebral haemor- 
rhage), 513 
Meningitis, simulated by cerebral form of 
pneumonia, 173 
epidemic cerebro-spinal, article on, 693 
anatomical lesions of, 695 
case of, 696 

paralysis following, 698 
eruptions in, 699 
treatment of, 701 
simple, article on, 503-510 

definition, synonyms, frequency, 503 
causes of, 503 
anatomical lesions in, 504 
symptoms of convulsive form, 505 

of phrenitic form, 506 
course and duration of, 507 
diagnosis of.from congestion of brain, 

507 
differential diagnosis of, 507 

from tubercular form, 488 
prognosis in, 508 
treatment of, 508 
bleeding in, 508 
calomel in, 509 

cold and counter-irritation in, 509 
tuberc7dar, article on, 473-507 

definition, synonyms, and frequency, 

473 
predisposing causes of, 474 
exciting causes of, 475 
pathology of, 475 
anatomical lesions in, 475 
microscopical changes in, 476 
division into stages, 479 
mode of invasion, 480 
symptoms of first stage, 481 
hydrencephalic cry, 482 
condition of mind in, 482 
use of ophthalmoscope in, 483 
convulsions in, 483 
circulation in. 484 
•symptoms of second stage, 484 
tache meningitique, 485 
nervous symptoms in, 485 
decubitus in, 485 
pulse in, 485 
respiration in, 486 
temperature in, 487 
diagnosis of, from simple meningitis, 
487 
from typhoid fever, 489 
cases simulating, 490 
prognosis in, 490 
cases of recovery from, 491 
case of apparent recovery from, 491 
prognosis not absolutely hopeless, 493 
uncertainty of date of death in, 494 
treatment of. 494 
bleeding not to be used, 494 
iodine and iodide of potassium in, 495 



INDEX, 



999 



Meningitis, counter irritation in, 497 
cold applications in, 497 
calomel and mercury in, 497 
prophylaxis in, 498 
narcotics in, 499 
diet in, 500 
importance of country residence, 

501 
illustrative case, 501 
Mental condition in rickets, 866 
MercurinI ointment to prevent pitting in vari- 
ola. 808 
in congenital syphilis, 881 
applications in eczema, 917 
in favus, 952 
in tinea, 956 
Mercury (<(?e Calomel). 

in membranous croup, 100 
in pneumonia, 184 
in pleurisy, 288 
in entero-colitis, 403 

in diseases of coecum and appendix, 454 
in tubercular meningitis, 497 
in simple meningitis, 509 
in chronic hydrocephalus, 529 
in scrofula, 847 
in congenital syphilis, 881 
Mesenteric glands, tuberculosis of, 851, 858 
Metastasis in mumps, 687 
Microscopic examination of milk, 339 

of false membranes in diphtheria, 658 
changes in tubercular meningitis, 475 
in spinal cord in tetanus, 579 
in chorea, 591 
in infantile paralysis, 618 
in muscle in infantile paralysis, 616 

in progressive paralysis, 638 
in kidneys in scarlatinous dropsy, 
730 
Microsporon furfur, 945 
Miliary tubercles, 475 
Milk {see also Food and Diet). 

properties of, and mode of examining 

cow's milk, 326 
mode of preserving, 328 
proper dilution of, for infants, 328 
quantity of, for infants, 329 
preparation of, 331 
human, analysis of, 338 

microscopic examination of, 339 
mode of examining, and properties 

of, 339 
substitutes for, 325-331 
Milk-crust {see Eczema capitis), 905 
Morbilli {see Rubeola), 764 
Mortality (.vee Statistics). 
Mouth, examination of, 47 
mode of examining, 47 
diseases of {see Stomatitis), 296 
Mucous membrane, condition in entero-colitis, 
389 
of fauces in diphtheria. 658 
affections of, in congenital syphilis, 878 
of fauces, in scarlatina, 720 
gastro-intestinal. in scarlatina, 736 
eruption on, in small-pox, 791 
condition of, in small-pox. 798 

in cases of ascaris lumbricoides, 970 
Muguet {see Thrush). 
Mumps, article on, 685-689 

definition, synonyms, and frequency of, 

685 
causes of, 685 



Mumps, anatomical appearances in, 686 

symptoms of, 686 

characters of swelling in, 686 

salivary secretion in, 687 

general symptoms in. 687 

tendency to metastasis in, 687 

prognosis always favorable in, 688 

course and duration of, 688 

usually terminates by resolution, 688 

suppuration of parotid in, 688 

diagnosis of, 688 

treatment of, 688 

danger of febrile sequelae in, 689 
Muriate of ammonia {xfe Ammonia). 
Muriatic acid {s^e Acid). 
Murmur, cardiac, in chorea, 590, 594 

cerebral, in rickets, 866 
Muscle, condition of, in atrophic infantile 
paralysis, 616 
in progressive paralysis. 638 
Muscular sclerosis, progressive (56e Paralysis), 
628 

Nasal variety of diphtheria. 665 
Nature of spasmodic laryngitis, 73 

of pseudo-membranous laryngitis and 
diphtheria, 83 

of collapse of the lung, 139 

of pneumonia. 153 

of emphysema, 213 

of pneumothorax. 248 

of hooping-cough, 264 

of cyanosis, 280 

of aphthae, 388 

of thrush. 317, 323 

of tonsillitis, 344 

of simple diarrhoea, 364 

of gastritis, 374 

of entero-colitis, 393 

of cholera infantum, 420 

of diseases of coecum and appendix, 441. 
442, 446 

of cerebral congestion, 510 

of chronic hydrocephalus, 522 

of eclampsia, 539 

of laryngismus stridulus, 553 

of contraction with rigidity, 568 

of chorea. 595 

of atrophic infantile paralysis, 616 

of progressive muscular sclerosis, 637 

of diphtheria, 655 

of mumps, 685 

of rickets, 873 

of scarlatina, 705 

of rubeola, 764 

of variola, 788 

of varicella, 824 

of typhoid fever, 828 

of erysipelas, 889 

of herpes iris, 921 

of scabies, 924 

of prurigo, 939 

of parasitic skin diseases, 943 

of favus, 949 

of alopecia areata. 958 
Nephritis, after scarlatina, 728-735 
Nervous system, general remarks on diseases 
of 472 

symptoms [see Cerebral symptoms). 
Nettle-rash {see Urticaria), 899 
Neurosis, evidence in favor of hooping- 
cough being a, 263 



1000 



INDEX. 



Neurosis, evidence of laryngismus stridulus 
being ii, 552 

infantile paralysis not a, 618 
Niemeyer, indications for bleeding in pneu- 
monia, 183 

on lesions in catarrh of stomach, 376 
Night terror, 639 

case? of, 640 

pathology of, 642 

causes of, 643 

treatment of, 643 

Obstruction of the intestines {see Intussus- 
ception), 456 
Occipital bone, depression of, as cause of teta- 
nus, 576 
(Edema of face in bronchial phthisis. 853 

of neck in scarlatina, 722 

in varioh., 792 

in typhoid fever, 836 

in erysipelas, 891 

in sclerema, 96 I 
Ogle, J. W., on chorea, 585 
Oidium albicans {see Thrush), 315 
Oi7itmeiits {see Local applications). 

in treatment of seat-worms, 982 
Omentum, tuberculosis of, 851 
Ophthalmia, in variola, 805 
Ophthalmoscope in tubercular meningitis, 

483 
Opisthotonos in tetanus nascentium, 580 
Opium in catarrhal croup, 79, 81 

in membranous croup, 101 

in pneumonia, doses, and mode of admin- 
istering, 188 

in pleurisy, 237 

in thrush, 341 

in entero-colitis, 404 

in cholera infantum, 431 

in dysentery, 439 

in diseases of coecum and appendix, 455 

in eclampsia, 548 

in rheumatism, 649 

in variola, 804 

in typhoid fever, 840 
Otorrhoea, in scarlatina, 722, 735 
Ova of acarus scabiei, 925 
Oxyuris vermicularis {see Ascaris vermicu- 
laris), 966 

Packing, cold, in scarlatina, 755 
Pain, modes of expressing, 22 

in pneumonia, seats and peculiarities of, 

162, 171 
in pleurisy, seats and peculiarities of, 230 
abdominal, in intussusception, 463 
in tuberculous peritonitis. 858 
in variola, 789 
Palpation of thorax in pleurisy, 230 
Pancoast, J., on tracheotomy in croup, 108, 

117 
Papules, chapter on, 936 

in small-pox, 790 
Paracentesis, in pleurisy {see Pleurisy), 239- 
247 
thoracis, 245 
case of, 246 
in hydrocephalus, 530 
Paralysis, in tubercular meningitis, 485 
in cerebral hsemorrhage, 518, 521 
in chorea, 594 
in diphtheria, 574 
after scarlatina, 736 



Paralysis, atropine infantile, article on, 609- 
626 
history of and authors on, 609 
synonyms of, 611 
causes of, 611 
forms of and muscles affected in, 

612, 613 
mode of attack, 612 
reaches its maximum suddenly, 613 
condition of paralyzed muscles in, 613 
illustrative case of, 613 
at times temporary, 614 
at other times, followed by atrophy, 

614 
temperature lowered in palsied parts, 

614 
subsequent deformities in, 614 
duration of, 615 
prognosis in, 616 
electrical condition of muscles as aid 

in prognosis, 616 
microscopic examination of muscles 

in, 617 
anatomical lesions in and nature of, 

617 
cannot be considered reflex, 617 
primary condition usually one of 

spinal congestion, 618 
sclerosis of cord in a later stage, 619 
other lesions of cord occasionally 

met with, 620 
diagnosis of from other forms of pa- 
ralysis, 621 
from progressive muscular atro- 
phy, 622 
occasionally simulates eoxalgia, 622 
use of local treatment to spine in, 

622 
ergot, belladonna, and iodide of po- 
tassium in acute stage, 623 
iron and strychnia in later stage, 623 
use of electricity in, directions for 

choice of current, 623 
mechanical contrivances in treat- 
ment of, 624 
tenotomy to relieve deformity, 625 
necessity of pursuing treatment for 
years, 626 
facial, article on, 626, 627 
causes of, 626 
symptoms of. 626 

diagnosis of from cerebral hemi- 
plegia, 626 
prognosis in, 627 
treatment of, 627 
progressive, with apparent hypertrophy 
of the muscles {see Progressive 
muscular sclerosis), 628-639 
Parasite of thrush {see Oidium albicans). 

of favus {spe Achorion Schoenleinii), 944 
of tinea tricophytina {see Tricophyton), 

944 
of tinea versicolor {see Microsporon), 945 
of alopecia areata, 945 
Parasitic skin diseases, 942-964 
general remarks on, 942 
varieties of. 942 
nature of, 943 

mode of detecting fungus in, 943 
relation between fungus and the erup- 
tion, 943 
description of achorion Schoenleinii {spe 
Favus also), 944 



INDEX. 



1001 



Parasitic skin diseases, description of trico- 
phyton (see Tinea also), 944 
description of raicrosporon furfur (see 

Alopecia areata), 945 
relation of the various fungi in, 945 
Parasiticides, 952 
Parotid gland, condition of in mumps, 686 

suppuration of in mumps, 687 
Parotitis (set" Mumps). 

in typhoid fever, 836 
Paroxysm of hooping-cough, peculiarities of, 
255 
treatment of, 274 
of laryngismus stridulus, svmptoms of, 
557 
treatment of, 564 
of eclampsia, symptoms of, 537 

treatment of, 545 
in tetanus, 580 
in diphtheritic croup, 664 
Parrot, on thrush, 317, 320 
Pathology of catarrhal pneumonia, 158 
Pelvis, alterations of in rickets, 869 
Pemphigus infantilis (see Rupia escharotica). 
Pemphigus, in congenital syphilis, 877, 928 
article on, 928-930 
definition and synonyms of. 928 
forms and frequency of, 928 
causes of, 928 
symptoms of, 928 
duration of, 929 
diagnoi^is of, 929 
prognosis in, 929 
general treatment of, 930 
local treatment of, 930 
Pepper, Prof., case of laryngismus stridulus, 
566 
incotitinence of urine in chorea, 594 
Pericarditis, acute, symptoms and difficulty 
of detection of, 285 
prognosis in, 285 
anatomical appearances in, 286 
treatment of, 286 
chronic, 286 
Percussion of heart, 35 

of lungs, mode of performing,etc.,43,44,45 
in pneumonia. 163, 170 
in pleurisy, 229 
in bronchial phthisis, 854 
in pulmonary phthisis, 857 
Perforation of coecum, 450 
of appendix coeei, 451 
of intestine in typhoid fever, 835, 840 
from ascaris lumbricoides, 970 
Peritoneum, tuberculosis of (see Tuberculo- 
sis), 850, 857 
Peritonitis, from perforation of ccecum and 
appendix. 447 
tuberculous (sef Tuberculosis), 850, 857 
in scarlatina, 736 
Perityphlitis, in art. on dis. of coecum and 
appendix, 441-455 
definition, 442 
iliac abscess in, 443 
anatomical appearances in, 446 
symptoms of, 451 
Perspiration, tendency to profuse, in rickets, 

866 
Pertussis (sre Hooping-cough), 254 
Pharyngitis, simple, 346-351 

definition and frequency, 346 
causes of, 346 
lesions in, 347 



Pharyngitis, symptoms of, 347 
diagnosis of, 349 
prognosis in, 350 
treatment of, 350 
Phlyzacia (see Ecthyma), 933 
Phthisis (.«ee Tuberculosis). 
Physical signs (see Auscultation and Percus- 
sion). 
Physiognomy in diseases, 21 
in pneumonia, 162 
in pleurisy, 231 
in tetanus, 580 
in cases of worms, 972 
Pinkroot as a vermifuge. 977 
Pitting in variola (see under Variola), 793 
in varioloid, 797 
treatment to prevent, 806 
Pityriasis, symptoms of, 941 

treatment of, 942 
Pleurisy, article on. 226-247 

chronic physical signs of. 234 
definition, frequency, and forms, 226 
predisposing causes of, 226 
exciting causes of, 227 
anatomical lesions in. 227 
symptoms of .-icute form, 228 
physical signs from auscultation, 228 
percussion, 229 
inspection, 230 
palpation, 230 
rational sympto us, pain, cough, respira- 
tion, pulse, 230 
urine in, 233 
symptoms of chronic form, 233 

of empyema, 234 
diagnosis of, 235 
obscurity in early stage from violence of 

constitutional symptoms, 236 
prognosis and mortality in, 236, 237 
treatment of, 237-247 
bloodletting in. 237 
antimony in, 237 
mercury in. 238 

diuretics and purgatives in, 239 
external remedies in. 239 
paracentesis, 239-247 
indications for, 240 
objections to, 246 
Trousseau's rule in regard to, 241 
indicated in empyema, 242 
success greater in children, 242 
rules to guide in advising, 243 
mode of performing, 243 
after treatment, 244 
use of medicated injections through 
canula, 245 
illustrative case of chronic form, 246 
Pleuro-pneumooia. physical signs in, 230 

mortality in. 237 
Pneumonia, lobular, in reality collapse of the 
lung, 139 
croupous, 168 
catarrhal, dififerential diagnosis of, 178 

prognosis of, 179 
differences between condition of lung in, 

and in collapse, 141 
in hooping-cough, 261 
in measles, 774 
article on, 153-190 
definition and synonyms of. 153 
frequency and mortaliry of. 153 
forms and classification, 153, 154 
hbular, identity of with collapse, 139, 154 



1002 



INDEX. 



Pneumonia, predisposing causes, 154 
nge at which most frequent, 155 
table showing influence of season, 156 
relation of mortality from, to the tem- 
perature, J 56 
exciting causes of, 156 
anatomical lesions of, 156 
of lobular form, 157 
of partial form. 158 
abscess of lung following, 158 
difference between condition of lung in, 
and in non-inflammatory congestion, 
159 
inflation of lung impossible in, 159 
usually unilateral, 159 
portion of lung involved in, 160 
apex quite frequently the seat of, 160 
not so frequently attended by bronchitis 

as formerly thought, 160 
association with pleurisy, 161 

with emphysema, 161 
general course of, in young children, 161 

in children over two years old. 165 
varieties of mode of onset, simulating 

other affections, 165 
unfavorable symptoms and modes of 

death, 167 
general course of the partial form, 168 
duration of, 169 
physical signs of, 170 
cough in, 170 
expectoration in, 171 
thoracic pain in. 162, 171 
state of respiration in, 162, 172 
physiognomy in, 172 
grade of fever in, 163, 173 
rate of pulse in, 163, 166, 173 
nervous symptoms, convulsions, 173 
appetite, vomiting, diarrhoea in, 174 
thirst in, 174 

urine, albuminuria in, 174 
chlorides in, 175 
diagnosis from bronchitis, 175 

from pleurisy, 175 

of catarrhal form, 175 

of cerebral form, 176 

during teething, 177 

from t.vphoid fever, 836 
prognosis of, 178 
treatment of, 179-190 
question of bloodletting in treatment of, 

183 
indications for bleeding in, 182 
use of antimony in, 183 

calomel in, 184 

salines in, 184 

muriate of ammonia in, 185 

quinia in, 185 

ipecacuanha in. 185 

purgatives in, 186 

external apfilications in, 186 
tonics and stimulants in, 187 
diet in, 187 
use of opium in, 187 
general management of, 189 
diet in, 189 

importance of administration of water in, 
189 

confinement to bed, 189 

change of position in, 190 
scrofulou?, 844 

relations of to tuberculosis of the lungs, 
848, 857 



Pneumonia in typhoid fever, 835 
Pneumothorax, from rupture of abscess of the 
lung, 158 
article on, 248 
nature of, 248 

anatomical appearances in, 248 
case of, 250 
causes of. 250 

phthisis, pneumonia, gangrene, and 

emphysema, 251 
symptoms of, 251 
course of, 252 
prognosis in, 252 
diagnosis of, 253 
treatment of, 253 
Pock, anatomy of variolous, 799 

of vaccine, 810 
Pompholyx (sfe Pemphigus), 928 
Porrigo {see Tinea), 953 
Porrigo larvalis {sf-e Eczema capitis), 905 
granulata (s^e Eczema granulatum), 908 
favosa {see Favus), 947 
scutulata {see Favus), 948 
Position recommended in atelectasis, 142 
Post-pharyngeal abscess {see Retropharyn- 
geal), 351 
Potash, carbonate of, in hooping-cough. 268 
and acetate of, in rheumatism, 649 
chlorate of, in ulcerative stomatitis, 203 
in diphtheria, 682 
in scarlatina, 745, 758 
caustic solutions of, in eczema, 916 
Potassium, iodide of, in pleurisy, 238 

in chronic valvular disease of the 

heart, 294 
in tubercular meningitis, 495 
in chronic hydrocephalus, 530 
in infantile paralysis, 623 
in rheumatism, 648 
in scrofula, 847 
in congenital syphilis, 881 
sulphuret of, baths of, in chorea, 606 
Poultices in pneumonia, 186 
in bronchitis, 208 
in eczema, 915 
in favus, 950 
Prickly- heat {see Lichen tropicus), 937 
Prognosis in simple laryngitis without spasm, 
65 
in spasmodic simple laryngitis, 77 
in pseudo-membranous laryngitis, 96 
in atelectasis pulraonum, 136 
in collapse of the lung, 150 
in pneumonia, 178 
in bronchitis, 205 
in emphysema. 222 
in pleurisy, 236 
in pneumothorax, 252 
in hooping-cough, 263 
in acute pericarditis, 285 
in acute endocarditis, 288 
in chronic valvular disease of the heart, 

290, 291, 292 
in aphthse, 299 
in ulcerative stomatitis, 302 
in gangrene of the mouth, 311 
in thrush. 324 
in tonsillitis, 343 

in chronic enlargement of tonsils, 345 
in simple pharyngitis, 350 
in retropharyngeal abscess, 353 
in indigestion, 358 



INDEX. 



1003 



Prognosis in simple diarrhoea, 369 
in gastritis, 378 
in entero-colitis, 398 
in cholera infantum, 427 
in dysentery, 438 

in diseases of coecum and appendix, 452 
in intussusception, 465 
in tubercular meningitis, 490 
in simple meningitis, 508 
in cerebral haemorrhage, 520 
in chronic hydrocephalus, 528 
in eclampsia, 543 
in laryngismus stridulus, 560 
in contraction with rigidity, 570 
in tetanus, 581 
in chorea, 599 

in atrophic infiintile paralysis, 616 
in facial paralysis, 626 
in progressive muscular sclerosis, 635 
in acute rheumatism, 647 
in diphtheria, 669 
in diphtheritic paralysis, 676 
in mumps, 688 
in malarial fever, 691 
in rickets, 870 
in tuberculosis, 860 
in congenital syphilis, 880 
in scarlatinous dropsy, 735 
in scarlatina, 740 
in rubeola, 780 
in variola, 802 
in varioloid, 802 
in varicella, 826 
in typhoid fever, 836 
in scrofula, 845 
in erythema, 886 
in erysipelas, 892 
in roseola, 898 
in urticaria, 901 
in eczematous affections, 911 
in herpes, 922 
in scabies, 926 
in pemphigus, 929 
in rupia, 932 
in ecthyma, 935 
in strophulus, 937 
in lichen, 938 
in prurigo, 940 
infovus, 950 
in tinea, 955 
in alopecia areata, 959 
in sclerema, 962 
in ascaris lumbricoides, 975 
in ascaris vermicularis, 981 
Progressive muscular sclerosis, article on, 
628-639 

definition of, 628 

history and synonyms of, 628 

causes of, 628 

symptoms of, 630 

peculiar gait in, 629 

condition of muscles in, 630 

produces club-foot, 631 

electrical condition of muscles in, 631 

appearance of skin in, 631 

temperature in, 631 

cause of, 632 

mental condition in, 635 

duration variable, 635 

termination fatal, by affection of re- 
spiratory muscles, 635 

diagnosis of, 635 

anatomical appearances in, 636 



Progressive muscular sclerosis, treatment of, 

639 
Prurigo, article on, 939 

definition of, 939 

frequency of, 939 

causes of, 939 

symptoms of, 939 

duration of, 939 

diagnosis of. from strophulus or lichen, 
939 
from scabies, 926 

prognosis in, 940 

treatment of, 940 
Pseudo-hypertrophic muscular paralysis {scp- 

Progressive muscular sclerosis), 628-639 
Pseudo-membranous angina {see Diphtheria), 
651 
in true croup, 88 
laryngitis {see Laryngitis). 
Psoriasis, diffusa, symptoms of, 941 

gnttnta, symptoms of, 941 
treatment of, 941 
Pulmonary resonance, characters of, in chil- 
dren, 44 

tuberculosis. 848, 857 
Pulse, in children, 33, 34, 35 

rate of, at different ages, 33, 34 

intermittence or irregularity of, 35 

irritability of, 35 

to be examined during sleep, 33 

peculiarities of, in tubercular meningitis, 
484, 486 

in mild cases of scarlatina, 711 

in grave cases of scarlatina, 717 

in variola, 792 

in typhoid fever, 834 
Purgatives {see Formulae) in pleurisy, 239 

in diseases of coecum, 454 

in intussusception, 468 

in eclampsia, 546 

in chorea, 601 

in rheumatism, 649 

in scarlatina, 745, 762 

in scarlatinous dropsy, 762 

in rubeola, 983 

in variola, 804 

in eczema, 912 

in worms, 976 
Pustules in variola, 791 

chapter on, 933 

Quinia in pneumonia, 187 

in bronchitis, 210 

in entero-colitis, 407 

in tetanus, 583 

in rheumatism, 649 

in diphtheria, 682 

in malarial fever, 692 

in variola, 804 

in typhoid fever, 840 
Quinsy (se^ Tonsillitis), 342 

Rachitis {see Rickets). 

Radeliffe, J. N., electrical condition of mus- 
cles in infantile paralysis, 616 
Rashes, 883 

Raw meat, use of, in entero colitis, 410 
Reaction of cow's and human milk, 316, 339 
Recession of base of chest in inspiration, 40 
Rees, Gr. A , recession of base of chest in in- 
spiration, 41 
respiration in collapse of the lung, 133 



1004 



INDEX. 



Reflex irritability exaggerated in early stage 

of pleurisy, 286 
Relapses of chorea, 595 

of acute rheumatism, 646 
of typhoid fever, 881 
Remittent Fever (see Typhoid fever). 
Residence, change of, in laryngismus stridu- 
lus. 564 
in unhealthy localities, influence of, 398 
change of, in treatment of entero-eolitis, 

399 
in country, importance of, 399 
Resonance, pulmonary, character in children, 

44 
Respirations, general characters of, in chil- 
dren. 38, 39, 40, 41, 43 
rate of, 39 
expiratory, 40 
diagnostic signs from. 41 
peculiar in atelectasis and croup, reces- 

.sion of base of thorax, 41, 93, 133 
puerile, 44 

alteration of, in simple laryngitis, 62 
in catarrhal croup, 76 
in true croup, 92 
in pneumonia. 162, 173 
in bronchitis, 203 
in pleurisy, 231 
in bronchial phthisis, 853 
in typhoid fever, 829, 830. 834 
in sclerema, 962 
Respiratory muscles affected in some cases of 
chorea, 593 
organs, diseases of, 51 
sounds, 43 
Rest, importance of, in cholera infantum, 433 
in bed, importance of, in rheumatism, 650 
Retropharyngeal abscess, 351 

definition, causes, symptoms of, 351, 352 
diagnosis, prognosis, treatment of,352, 353 
Return-cry, alteration of, 27 
Revaccination. 821 
Rhagades in congenital syphilis, 878 
Rheumatism as a cause of heart disease, 285 
of chorea, 586 
in scarlatina, 736, 760 
acute, article on, 645-650 
symptoms of. 645 
temperature in, 646 
condition of joints in, 646 
local symptoms often comparatively 

slight. 646 
duration and tendency to relapses. 

646 
causes of, 647 
influence of sex not yet determined, 

647 
chorea as complication of, 587 
heart disease as complication of, 284 
prognosis in. 647 

diagnosis difficult when local symp- 
toms are slight, 647 
treatment of, 648 
alkalies in, 648 
iron and quinia in, 649 
opium in. 649 
local applications in, 650 
importance of strict rest in bed, 650 
diet in, 650 

treatment of complications, 650 
Richardson, B. W., heart-clot in diphtheria, 

673 
Rickets, article on, 863-875 



Rickets, frequency of, in England and Amer- 
ica, 863 
bibliography of, 864 
causes of, 865 

symptoms of initiatory stage, 866 
digestive disturbances in, 866 
general soreness of body in. 866 
tendency to profuse perspiration in, 866 
dentition impeded in, 866 
urine in, 866 
mental condition in, 866 
cerebral blowing murmur in, 866 
stage of deformity, 867 
alterations of long bones in, 867 
of head in, 868 
of spine in, 868 
of thorax in, 869 

of thorax due to atmospheric pres- 
sure, 869 
of pelvis in, 869 
general symptoms in later stage, 869 

in favorable cases. 870 
secondary diseases causing death in, 870 
prognosis and duration in, 870 
diagnosis of, 871 

morbid anatomy of bones in, 871 
collapse of lung in, 872 
condition of viscera in, 872 
pathology of, 873 
treatment of, 874 
importance of proper diet in, 874 
cod-liver oil in. 875 
means of avoiding deformities, 875 
Rilliet and Barthez, size of heart by percus- 
sion, 36 
diagnosis between true and false 

croup, 74 
atelectasis and collapse of the lung, 

140 
state of vessels in gangrene of the 

mouth, 306 
diagnosis of gangrene of the mouth 
from ulcero-membranous stoma- 
titis, 309 
lesions in diarrhoea, 366 
on pathology of cholera infantum, 422 
diagnosis of simple from tubercular 

meningitis, 487 
diagnosis of simple meningitis from 

congestion of the brain, 507 
diagnosis of symptomatic from essen- 
tial contraction, 570 
on convulsions in scarlatina, 742 
cold aff'usion in scarlatina, 749 
Ringworm (s^e Tinea), 953 
Robinson, on heart-clot in diphtheria, 674 
Roger, pulse in children, 33 
respiration in children, 39 
and Barth, auscultation in croup, 94 
Rokitansky, on changes in spinal cord in teta- 
nus, 579 
Rosalia, or rubeola notha, 740 
Rosoola. epidemic, or rubeola notha, 740 
article on, 896-899 
definition and synonyms, 896 
frequency of, 896 
forms of, 896 

causes : occasionally epidemic, 896 
symptoms of; eruption, 896 
duration of, 897 
annulata. 

symptoms of, 897 

diagnosis of, from scarlatina, 897 



INDEX. 



1005 



Roseola annnlnta. diagnosis from rubeola, 897 
from herpes iris, 921 
prognosis in, 898 
treatment of. 899 
Round-worm (sie Ascaris lumbricoides), 965 
Rubeola, article on, 764-787 
definition of. 764 
forms of, 764 
frequency of, 702, 764 
epidemic nature of, 764 
contagiousness of, 765 
period of incubation of, 765 
influence of age on frequency of, 765 
straw-fungus as cause of, 766 
mode of invasion of regular form of, 766 
fever in initial stage of. 766 
catarrhal symptoms in initial stage of, 767 
marked drowsiness in initial stage of, 767 
convulsions in initial stage of, 768 
red papules on palate in initial stage of, 

768 
duration of initial stage of, 768 
date of appearance of eruption in, 769 
characters of eruption in, 769 
symptoms during eruption in, 769 
duration of eruption in, 770 
urine during eruption in, 770 
symptoms of stage of decline of, 770 
desquamation in, 770 
temperature in, 771 
irregularities of prodromic stage in, 771 

of eruption, 771 
petechial character of eruption without 

any malignant symptoms, 772 
form of, without eruption, 772 
notha or sine cu tar r ho, a form of roseola, 

772 
malignant form of, 773 

eruption in, 773 
complications and sequelae of, 773-778 
bronchitis and pneumonia in, 774 

effect of upon eruption, 774 
prognosis in bronchitis and pneumonia in, 

775 
laryngitis in, 775 
enteritis in, 776 

frequency of, 776 

causes of, 776 

symptoms of, 776 
fatal cerebral symptoms in, 776 
cases of, 776 
serous effusions in, 777 
tendency of, to develop tuberculosis, 778 
coexisting with variola, scarlatina, or 

erysipelas, 778 
anatomical lesions in, 778 
diagnosis of, 779 

from roseola, 779, 898 

from variola, 779 

from typhus, 779 
prognosis in, 780 
causes of death in, 780 
hygienic treatment of, 781 
diet in, 782 

laxatives and febrifuges in, 782 
depletion in, 783 
treatment of malignant form of, 784 

of pulmonary complications in, 784 
counter-irritation in pulmonary compli- 
cations in, 785 
treatment of diarrhoea in, 786 

of laryngitis in, 786 

of cerebral symptoms in, 786 



' Rupia, article on, 930-933 

definition of, 930 

varieties of. 930 

causes of, 931 

symptoms of, 931 

diagnosis of, from pemphigus, 932 
from ecthyma, 932 

prognosis in, 932 

general treatment of. 932 

local treatment of, 933 
siinplex. 

symptoms of, 931 
•pro mine as. 

symptoms of, 931 
eschar utica. 

symptoms of, 931 

Salines, in treatment of membranous croup, 
101 
of pneumonia. 185 
Salisbury, on straw fungus as cause of mea- 
sles, 766 
Salivary secretion in mumps. 687 
Santonin as a vermifuge, 979 
Scabies, article on, 923-928 

definition of, 923 

caused by acarus scabiei, 924 

seat of eruption in, 924 

local symptoms in. 924 

character of eruption in, 924 

cuniculi in, 924 

mode of detecting acarus, 925 

general symptoms of. 925 

description of the acarus, 925 

diagnosis of, by finding acarus or its ova, 
925 
from eczema simplex, 910, 926 
from prurigo. 926 
from lichen, 926 

prognosis in, 926 

treatment of, 926 

applications of sulphur in (.<te^ Formulae), 
927 

substitutes for sulphur in, 927 

tarry arplications in. 927 

carbolic acid in, 927 

general tre.itment of, 927 
Scarlatina, article on, 702-764 

definition of, 702 

frequency of, 702 

forms of, 703 

contagion as a cause of, 705 

period of incubation of, 705 

transmitted by fomites, 706 

inoculability of, 706 

epidemic nature of, 706 

occasional occurrence of second attacks 
of, 707 

influence of age upon frequency of, 707 
of sex upon. 708 

symptoms of mild cases of, 709-714 

invasion generally suddea in, 709 

occasionally a short prodromic stage.. 710 

characters of eruption in. 710 

duration of eruption in, 710 

pulse and fever in stage of eruption, 711 

tongue in stage of eruption, 711 

urine in stage of eruption, 712 

fauces in stage of eruption, 712 

symptoms of decline of, 712 

desquamation in, 713 

duration of mild cases, 713 

temperature in, 713 



1006 



INDEX. 



Scarlatina, no sharp line between mild and 
grave cases, 714 

symptoms of grave cases of. 714-728 

sudden invasion in ataxic form of, 715 

case of, 715 

general symptoms in ataxic form of, 717 

convulsions in ataxic form of, 717 

delusive improvement in ataxic form of, 
718 

eruption in ataxic form of. 718 

fatal symptoms in ataxic form of. 718 

invasion of grave cases sometimes less 
sudden, 719 

condition of fauces in grave cases, 720 

pseudo-membrane in, 721 

swelling of submaxillary and cervical 
glands in grave cases, 721 

coryza and otorrhoea in grave cases, 722 

eruption in grave cases, 728 

general symptoms in grave cases, 723 

cases of this grave form, 724 

laryngitis in grave form, 725 

duration of grave form, 728 

complications and sequelae of, 728-735 

dropsy as a sequel of, 728-735 

preceded by albuminuria, 728 
frequency of, very variable, 729 
period of occurrence, 729 
usually due to cold, 729 
due to tubal nephritis, 730 
condition of kidneys in, 730 
preceded by febrile symptoms, 731 
seat of effusion in, 732, 734 
course and duration of, 732 
modes of death in, 732 
urasmic symptoms in. 732 
urine greatly diminished in, 733 

characters of, in, 734 
prognosis in, 735 
uraemia not necessarily fatal, 735 

diarrhoea as a complication of, 735 

rheumatism during, 735 

inflammation of serous membranes in, 736 

endo- or pericarditis in, 736 

peritonitis in, 736 

complicated with variola, measles, or 
diphtheria, 736 

paralysis after, 736 

anatomical lesions in, 736 

condition of gastro-intestinal mucous 
membrane in, 736 
of skin in, 737 
of blood in, 737 

connection of, with enteric fever, 737 

heart-clot in, 738 

diagnosis of from measles, 739 
from roseola, 739. 897 
from diphtheria, 670, 740 
from rubeola notha, 740 
from erythema fugax, 883 

prognosis in, very variable in different 
epidemics, 740 
in mild cases, 741 
in grave cases, 741 

grave significance of convulsions in, 742 
unfavorable symptoms in, 743 

favorable symptoms in, 744 

hygienic treatment of, 744 
diet in, 746 

treatment of mild cases, 745-747 
use of warm baths and affusion in mild 
cases, 746 

care in use of purgatives in mild cases, 745 



Scarlatina, treatment of angina in mild cases, 

746 
inunction in, 746 
treatment of grave cases, 748-760 

cold affusions in grave cases, 748 
general remarks on baths, lotions, and 

affusions in grave cases, 751 
guide as to using cold in, 753 
best method of applying, 755 
temperature likely to continue to fall 

after application of, 755 
hyposulphite of soda and magnesia in, 

756 
use of tonics and stimulants in grave 

cases, 757 
treatment of angina in grave cases, 758 
external use of ice in grave cases, 759 
case of, 759 
importance of removing viscid secretions 

from throat, 760 
diarrhoea in, 760 

treatment of the rheumatism in, 760 
of otorrhoea, 760 

prophylactic of dropsy, 760 
of mild cases of dropsy, 762 
of severe cases of dropsy, 762 
diuretics in, 762 

hot baths as diaphoretics in dropsy, 762 

treatment of cerebral symptoms in 

dropsy, 763 

of the later stages of dropsy, 763 

use of belladonna as a prophylactic in, 763 

Sclerema, article on, 960-964 

definition and synonyms of, 960 
frequency of, 960 
date of occurrence of, 960 
causes of, 960 
atelectasis as cause of, 961 
extent of, 961 
condition of skin in, 961 
oedema in, 961 
temperature in, 961 
peculiar cry in, 961 
general symptoms of, 961 
symptoms of in later life, 962 
prognosis in, 962 
diagnosis of, 962 
anatomical appearances, 962 
condition of skin in, 962 
bloodvessels in, 963 
lungs in, 963 
treatment of, 964 
Sclerosis of spinal cord in infantile paralysis, 

619 
progressive muscular, 628 
Scrofula as sequel of hooping-cough, 267 
article on, 842-847 
definition and characters of, 842 
associated with tuberculosis, 842 
causes of, 843 
symptoms of, 843 ' 
•stages of, 844 

pneumonia and bronchitis in, 844 
albuminoid degeneration of viscera in, 

844 
anatomical appearances in, 845 
diagnosis of, 845 
prognosis in, 846 
treatment of, 846 

preventive of, 846 
iodine preparations in, 847 
mercury in, 847 
arsenic in, 847 



INDEX. 



1007 



Season, influence upon frequency of true 
croup, 87, 655 
pneumonia and bronchitis, 156 
diphtheria and croup, 654 
Senton, E. C, on vaccination, 820 
Seat-worm (see Ascaris vermicuhiri?), 966 
Second attacks of scarlatina, 707 
Secondary fever in variola, 792, 804 
See, on gymnastic exercises in chorea. 606 
Sensibility affected in diphtheritic paralysis, 

676 
Shingles {s>'e Herpes zoster), 920 
Sims, Marion, on cause of tetanus nascentium, 

676 
Silver, nitrate of, in chronic entero-colitis, 
413 
in dysentery, 440 
local application of in diphtheria, 

678 
in diphtheritic paralysis, 684 
local use of in scarlatinous angina, 
759 
to prevent pitting in variola, 806 
enema of, in worms, 982 
Skin, diseases of, general remarks on, 882 
examination of, 30, 31, 32 
color of, in infants, 30, 31 

in different diseases, 31 
exudation on, in diphtheria, 659, 660 
in congenital syphilis, 876 
in scarlatina («<?<? Eruption and desquama- 
tion), 
in measles {see Eruption and desquama- 
tion). 
in variola {see Eruption and desquama 

tion). 
in typhoid fever, 832 
gangrene of, in erysipelas, 891 
in sclerema, 961 
Sleep, diagnostic signs from, 23 
Small-pox (.«i^(' Variola). 787 
Smith, J. Lewis, on lesions in cyanosis, 277 
on symptoms in cyanosis, 281 
state of intestine in entero-colitis, 

388 
on liver in entero-colitis, 392 
Snuffles, 51 

Soaps in treatment of eczema, 917 
Soda, hyposulphite of, in scarlatina, 756 

in favus, 752 
Softening of stomach, 376 

of bones in rickets, 867 
Soreness of body in rickets, 866 
Sounds of heart, 35 
respiratory, 43 
Spasm of glottis {see Laryngismus stridulus), 
550 
carpopedal, 558, 569 
Spence, J., on tracheotomy in croup, 110 
Sphincters affected in chorea. 594 
Spigelia as vermifuge, 977 
Spinal cord in tetanus, 579 
in chorea, 591 
in infantile paralysis, 618 
column, alteration of, in rickets, 868 
Spiritus saponatus kalinu.*, 917 
Spleen, enlarged in typhoid fever, 833 
Squamae, chapter on, 940 
rare in children, 940 
Statistics of frequency and mortality of pneu- 
monia. 153, 15^, 179 
of bronchitis, 156, 190 
of pleurisy, 237 



Statistics after paracentesis in pleurisy, 242 
of true croup, 86, 652, 654 
after tracheotomy in true croup, 104- 

115 
of hooping-cough, 254, 263 
of thrush, 324 
of entero-colitis, 382 
of cholera infantum, 382, 436 
of nervous diseases, 472 
of tubercular meningitis, 484 
of eclampsia, 533. 543 
of laryngismus stridulus, 560 
of tetanus nascentium, 577 
of chorea, 584, 600 
of diphtheria, as compared with true 

croup, 86, 652, 654 
of rickets, 863 
of scarlatina, 702, 708, 740 
of rubeola, 702, 764 
of variola, 788 

of variola after vaccination, 820, 822 
of typhoid fever, 836 
of pulmonary tuberculosis, 849, 850 
Stimulus, indications for, in pneumonia, 187 
use of, in entero-colitis, 407 

in stage of collapse in cholera in- 
fantum, 431 
•in chorea, 605 
in diphtheria, 683 
in scarlatina, 768 
in variola, 804 
in typhoid fever, 840 
in erysipelas, 895 
Stomach and intestines, general remarks on 
diseases of. 353 
functional disease of {see Indiges- 
tion), 353 
diseases of, attended with lesions, 
374 
inflammation of {see Gastritis), 374 
condition in entero-colitis, 392 
eruption on, in variola, 798 
Stomatitis. 

in congenital syphilis, 878 
in small-pox, 792 
erytheni'i.tous. 
article on, 296 

definition and frequency of, 296 
causes of, 296 
symptoms of, 297 
treatment of, 297 
follicular. 

article on, 297-300 

definition, synonyms, frequency of, 297 
forms of, 297 
causes of, 297 

symptoms and duration of, 298 
diagnosis of, 298 
prognosis in, 298 
treatment of, 299 
ulcerative or nl cero-membranous . 
article on, 300-304 

definition, synonyms, frequency of, 300 
causes of, 300 

symptoms and course of, 301 
duration of, 301 
diagnosis of, 302 
prognosis in, 302 
treatment of, 302 
gangrenous. 

arlicle on, 304-315 

definition, synonyms, frequency of, 304 

causes of, 304 



1008 



INDEX. 



Stoniatilts, gavgrenous, anatomical lesions 
of, 305 

symptoms and course of, 306 

duration of, 309 

complications of, 309 

diagnosis of, 309 

prognosis in, 310 

treatment of, 311 
Stools, diagndstic signs from the, 49 

in simple diarrhoea, 369 

in acute entero-colitis, 394 

in chronic entero-colitis, 397 

in cholera infantum. 425 

bloody, in intussusception, 461 

in typhoid fever, 830, 831, 833 

in case of worms, 973 
Straw-fungus as cause of rubeola, 766 
Strophulus. 

article on, 936-937 

definition of, 936 

causes of, 936 

varieties and symptoms of, 936 

diagnosis of, 937 

treatment of, 937 

iiitertiiictiis or red gum, 936 

confertus, 936 

alhidns or lohite gnm, 936 
Strychnia in chorea, 604 

in infantile paralysis, 623 

in diphtheritic paralysis, 684 
Sucking, signs from mode of, 48 
Sudamina in typhoid fever, 830, 834 
Sugar in urine in hooping cough, 257 
Sulphurous applications in favus, 952 
Sulphur in treatment of scabies, 927 
Summer complaint {see Cholera infantum), 

416 
Suppurative fever in variola, 793, 804 
Swine-pox {see Varicella). 
Sympathetic nerve, affection of, in cholera 

infantum, 424 
Syphilis, congenital, article on, 875-881 

modes of trsmsmission of, to embryo, 876 

date of appearance of symptoms, 876 

condition of skin in, 876 

pemphigus and other eruptions in, 877 

coryza and stomatitis in, 878 

alteration of voice in, 878 

rhagades and condylomata in, 877 

course of, 878 

development of tertiary stage, 878 

alteration of teeth in, described by 
Hutchinson, 879 

interstitial keratitis in, 879 

affection of internal organs in, 879 

anatomical lesions in, 879 

diagnosis of, in early stage, 880 
in later stage, 880 
between inherited and acquired, 880 

prognosis in, 880 

treatment of, 881 

use of mercury in, 881 
Syphilis, transmitted by vaccination, 817 

Tabes mesenterica {see Tuberculosis of mesen- 
teric glands), 851 
Table of mortality {see Statistics). 
Tache meningitique in meningitis, 485 
Taenia solium, 966 

lata, 967 
Tape-worm (5e« Taenia), 966, 967 
Tarry applications in eczema, 917 
in scabies, 927 



Tarry applications in tinea, 956 

in favus, 952 
Tartar emetic {see Aniimony). 
Tears, arrest of in disease, 27 
Teeth, alteration of in congenital syphilis, 

879 
Temperature, normal at different ages, 37 

tables of observations on, 37 

effect of, on mortality of pneumonia and 
bronchitis, 156 

of body, low in cyanosis, 281 

in tubercular meningitis, 486 

lowered in infantile paralysis, 614 

in acute rheumatism, 646 

influence of, upon membranous croup, 87 

effect upon mortality of diphtheria and 
croup, 655 

in pulmonary phthisis, 855 

in scarlatina, 713 

in measles, 771 

in typhoid fever, 830, 832 

high, as cause of lichen, 938 

in sclerema, 961 

proper for sick-room, 781 
Tenotomy in infantile paralysis, 625 
Testicle, affected by metastasis in mumps, 687 
Tetanus nascentium, article on, 576-584 

definition and synonyms of, 576 

period of occurrence of, 576 

morbid conditions of umbilicus as cause 
of, 576 

Sims's view of displacement of occipital 
bone as cause of, 576 

general causes of, 577 

frequency of, 577 

anatomical lesions in, 578 

microscopic changes in spinal cord in, 579 

symptoms of. 579 

occurrence of paroxysm in, 580 

prognosis in, 581 

diagnosis of, 581 

duration of, occasionally chronic, 581 

prophylaxis in. 581 

treatment of, 581 

anaesthetics in, 582 

narcotics and antispasmodics in, 583 
Thermometer, observations with, in chil- 
dren, 37 
Thread-worm (s^e Ascaris vermicularis), 966 

{see Tricocephalus dispar), 966 
Throat, examination of, 48 

diseases of {see Pharyngitis), 346 
Thrush, article on, 315-342 

definition, synonyms of, 315 

frequency of, 315 

predisposing causes of, 315 

exciting causes of, 317 

anatomical lesions of, 317 

description of fungus of, 319 

symptoms of, 318 

nature of, 323 

diagnosis of, 323 

prognosis in, 324 

prophylactic treatment of, 324 

general treatment of, 324 

examination of cow's milk, 325 

mode of preparation of cow's milk, 328 

quantity of food necessary for children, 
329 

formula for gelatin food, 332 

examination of mother's milk, 339 

diet in, 339 

remedies useful in, 340 



INDEX. 



1009 



Thrush, local treatment of, 341 
Thymus gland, enlarged in laryngismus strid- 
ulus, 554 
Tinea lactea {see Eczema capitis), 905 

granulata {see Eczema granulatura), 908 

decalvans {see Alopecia areata), 958 
tricophytina, varieties of. 953 

identity of t. tonsurans and t. circinata, 
953 

synonyms of, 953 

description of its fungus, tricophyton, 944 

contagion as cause of, 953 

other causes of, 953 

general treatment in, 956 

local treatment in, 956 

epilation in, 956 

alkaline applications in, 956 

mercurial applications in, 956 

tarry applications in, 956 

cases of, 957 
tonsurans. 

eruption in, 954 

character of hairs in, 954 

condition of scalp in, 954 

diagnosis of, 955 

prognosis of, 955 
circinata. 

eruption in, 955 

character of hairs in, 955 

diagnosis of, 955 
Tongue in scarlatina, 712 
Tonsils, sloughing of, in diphtheria, 661 

condition of, in scarlatina, 721 

acute inflammation of (.<e^ Tonsillitis), 342 

chronic enlargement of, 344 

nature and causes of, 344 

anatomical appearances in, 344 

symptoms of, 344 

prognosis in, 345 

treatment of 345 
Tonsillitis, 342 

definition of, 342 

symptoms of, 342 

causes and duration of, 343 

prognosis in, 343 

diagnosis of, 343 

treatment of, 343 
Tracheotomy, in membranous croup. 103 

statistics of its performance in different 
countries, 104-108 

estimation of its value, 107 

dangers of the operation, 108 

rules to guide in advising, 109, 114 

proper period for performing, 109 

indications for, 1 10 

influence of period of performance upon 
result. 111 

contraindications, 112-114 

age as a contraindication, 111 

successful cases at early age. Ill 

extension of false membrane into the 
bronchia as a contraindication, 112 

negative results of auscultation, 112 

presence of pneumonia as a contraindica- 
tion. 113 
general diphtheria as a contraindica- 
tion, 114 

contraindicated in secondary forms of 
croup, 114 

twice successfully performed in same sub- 
ject, 115 

mode of performing, 115-119 

instruments required in performing, 115 



Tracheotomy, details about canulas, 116' 

substitutes for canulas, 117 

question of fixing trachea in, 117 

excising piece of trachea in. 117 

mode of performing, 1 18 

emphysema of neck following. 119 

use of anaesthetics during, 119 

after-treatment, 119-123 

great importance of, 120 

modes of rendering inspired air moist, 120 

treatment of wound, 120 

instillation and atomization into trachea 
after, 121 

directions for cleansing tubes after, 121 

mode of removing canula, 121 

date of removing canula, 122 

causes of delay in removing canula, 122 

general after-treatment, 123 

importance and manner of feeding pa- 
tients, 123 

question of medication after, 124 

difficulty of deglutition following, 123 

illustrative cases of, 124 
Treatment of coryza, 56 

of simple laryngitis without spasm, 65 

of chronic laryngeal cougb. 65 

of spasmodic simple laryngitis, 77 

of pseudo-membranous laryngitis, 96 

of atelectasis pulmonum, 137 

of collapse of the lung, 150 

of pneumonia, 179 

of bronchitis, 205 

of emphysema, 223 

of pleurisy, 237 

of pneumothorax, 253 

of hooping-cough, 264 

of complications in, 272 
of paroxysm of, 274 

of cyanosis, 283 

of acute pericarditis. 286 

of chronic pericarditis, 286 

of acute endocarditis, 287 

of chronic valvular disease. 292 

of erythematous stomatitis, 297 

of ap'hthiB, 299 

of ulcerative stomatitis, 302 

of gangrene of the mouth, local, 311 

of gansrene of the mouth, general, 314 

of thru'sh, 324 

of tonsillitis, 343 

of chronic enlargement of tonsils, 345 

of simple pharyngitis, 350 

of retropharyngeal abscess, 353 

of indigestion, 358 

of simple diarrhoea, 370 

of gastritis. 378 

of enlero-colitis, 398 

of cholera infantum, 428 

of dysentery. 438 

of diseases of coecum and appendix, 453 

of intussusception, 468 

of tubercular meningitis, 494 

of simple meningitis. 508 

of cerebral congestion, 512 

of cerebral haemorrhage, 520 

of chronic hydrocephalus, 529 

of eclampsia, 544 

of laryngismus stridulus. 561 

of contraction with rigidity, 570 

of tetanus nascentium, 581 

of chorea, 608 

of atrophic infantile paralysis, 622 

of facial paralysis, 627 



64 



1010 



INDEX. 



Treatment of progressive muscular sclerosis, 
639 

of acute rheumatism, 648 

of diphtheria, 678 

of mumps, 688 

of malarial fever, 692 

of rickets, 874 

of tuberculosis, 861 

of congenital syphilis, 881 

of scarlatina, 745 

of scarlatinous dropsy, 760 

of measles, 781 

of variola, 803 

of varicella, 826 

of typhoid fever, 839 

of scrofula, 846 

of erythema, 886 

of erysipelas. 892 

of roseola. 899 

of urticaria, 901 

of eczematous affections, 911 

of herpes, 922 

of scabies, 926 

of pemphigus, 930 

of rupia, 932 

of ecthyma, 935 

of sti'ophulus, 937 

of lichen, 938 

of prurigo, 940 

of psoriasis, 941 

of pityriasis, 942 

of ichthyosis, 942 

of favus. 950 

of tinea, 956 

of alopecia areata, 955 

of sclerema, 964 

of ascaris lumbricoides, 976 

of ascaris vermicularis, 981 
Tricocephalus dispar, 966 
Tricophyton, description of (5^e Tinea also), 

944 
Trismus {see Tetanus). 

Trousseau, on tracheotomy in true croup, 
105, 106, no, 114 

on paracentesis, 240-245 

on compression of the head in hydroceph- 
alus, 530 
Tube-casts in urine in diphtheria, 671 

in scarlatina, 734 
Tubercular meningitis {see Meningitis), 473 
Tuberculosis, as sequel of typhoid fever, 836 
of measles, 778 
of hooping-cough, 261 

of meninges {see Meningitis), 473 

associated with scrofula, 842 

article on, 848 

causes of, 848 

relation of, to pneumonia, 848 

apt to involve several viscera simultane- 
ously, 848 

of bronchial glands, anatomical appear- 
ances of, 849 

of lungs, anatomical appearances of, 849 

of peritoneum, anatomical appearances 
of, 850 

of omentum, anatomical appearances of, 
850 

of mesenteric glands, anatomical appear- 
ances of, 851 

term used to include cheesy products not 
strictly tuberculous, 851 

of bronchial glands, symptoms of, 853 
characters of cough in, 853 



Tuberculosis of bronchial glands, pressure on 
veins in, 853 
physical signs of, 853 
peculiarities of, 854 
pulmonary symptoms of, 855 
importance of general symptoms in, 

855 
character of cough in, 855 
hcemoptysis rare in, 855 
temperature in, 855 
peculiarities of physical signs in, 856 
pneumonia in, 857 
duration of, at times great, 857 
occasional recovery in, 857 
of peritoneum, symptoms of, obscure, 857 
digestive disturbances in, 858 
pain in, 858 

enlargement of abdomen in, 858 
tumor v?hen omentum is affected, 858 
course of, 858 
modes of death in, 858 
of mesenteric glands, symptoms of, 858 

enlargement of abdomen in, 859 
detection of tumor in, 859 
digestive disturbances in, 859 
duration of, 859 
diagnosis of, 859 

from remittent fever, 860 
from typhoid fever, 838 
pulmonary, diagnosis of, from chronic 

bronchitis, 860 
of peritoneum, diagnosis of, fropa simple 

distension of abdomen, 860 
of mesenteric glands, diagnosis of, from 

abdominal tumors, 860 
prognosis in, 860 
possibility of recovery from, 861 
modes of death in, 861 
treatment of, prophylactic, 861 

curative, 862 
use of tonics in, 862 
diet in, 862 
cod-liver oil in, 862 
treatment of complications, 863 
Tuberculous pneumonia, 857 

peritonitis {see Tuberculosis of perito- 
neum). 
Tuckwell, on chorea, 586 
Tumor, abdominal, in diseases of coecum and 
appendix, 450 
in intussusception, 463 
in tuberculosis of mesenteric glands, 

859 
in tuberculosis of omentum, 859, 860 
diagnosis of, 860 

gummy, in congenital syphilis, 880 
Turpentine as a vermifuge, 977 
Turpeth mineral in pseudo-membranous laryn- 
gitis, 100 
Typhlitis, in article on diseases of coecum and 
appendix, 441-455 
synonyms of, 442 
seat and character of. 442 
causes of, 443 

anatomical appearances of, 446 
cases of, 447 
symptoms of, 449 

of perforation of the coecum during, 
450 
duration of, 451 
prognosis in, 452 
diagnosis of, 452 
treatment of, 453 



INDEX. 



1011 



Typhoid fever, diagnosis from tubercular 
meningiti:!, 490 

article on, S27 

formerly confounded with remittent fever, 
827 

causes of. 827 

bat slightly contagious, 827 

epidemic nature of, 827 

anatomical appearances in, 828 

condition of intestine in, 828 

condition of blood in, 828 

condition of brain in, 828 

symptoms of ordinary cases, 829 

marked remissions in febrile action, 829 

prodromes in, 829-832 

eruption in, 834 

symptoms of fully developed attack, 832 
of grave cases, 834 

favorable symptoms in, 831 

unfavorable symptoms in. 830 

digestive disturbances in, 832 

character of stools in. 833 

distension of abdomen in, 833 

enlargement of spleen in, 833 

urine in, 833 

respiration in, 834 

pulse in, 834 

nervous symptoms in, 834 

pulmonary complications in, 835 

perforation of intestine in, 835 

intestinal haemorrhage in, 835 • 

albuminuria and oe lema in, 836 

complicated with malaria or one of the 
eruptive fevers. 836 

tuberculosis as sequel of, 836 

convalescence in, 836 

relapses in, 837 

duration of, 837 

prognosis and mortality in, 837 

diagnosis of, from gastro-enteritis, 838 
from typhoid pneumonia. 838 
from acute tuberculosis, 838 

treatment of febrile symptoms in, 839 
of gastric irritability in, 839 
of intestinal symptoms in, 840 
of nervous symptoms in, 840 
of complications in, 840 

use of quinia in, 840 

use of opium in, 840 
stiufulants in, 840 

diet in, 840 

management of convalescence, 840 

Ulceration of internal malleoli in thrush, 322 

of mucous membrane of fauces in diph- 
theria, 658 
in scarlatina, 721 

in erythema intertrigo, 88-1 
Umbilicus, morbid states of, as cause of teta- 
nus, 576 
Umbilication of variolous pock, cause of, 799 
Uraemia, in scarlatinous dropsy, 732 
Urine in pneumonia, 174 

in bronchitis. 203 

in pleurisy, 233 

in hooping-cough, 257 

in chorea. 594 

in diphtheria, 668 

in rickets. 866 

in scarlatina, 712 

in scarlatinous dropsy, 733 

in measles, 770 

in variola, 794 



Urine in typhoid fever, 833 
Urticaria, article on, 899-902 

definition and synonyms of, 899 

forms of. 899 

causes of, 899 

symptoms of, 900 

diagnosis of, 901 

prognosis in, 901 

treatment of, 901 

diet in, 902 

Vaccina (see Vaccine disease). 
Vaccination (see under Vaccine disease). 
Vaccine disease, article on, SU9-S24 

definition and synonyms of, 809 

history of, 809 

date of appearance and development of 
pock, 810 

cellular character of pock, 810 

local and general symptoms in, 811 

desiccation and desquamation in, 811 

character of cicatrix after, 811 

irregularities and course of, fcl2 

severe local symptoms in. 812 

erysipelas following. 889 

appearance of pock retarded, 812 

spurious form of, 813 

diagnosis of, 813 

protective power of against variola, 813 
cases illustrative of, 814 
against death, 820 
Vdccinatiou . period of performing, 816 

susceptibility to, variable, 816 

efi"ect of cutaneous eruptions on. 817 

alleged transmission of cutaneous dis- 
eases by, 817 
of syphilis by, 817 

forms of virus employed, 819 

characters of good vaccine crust, 819 

modes of introducing virus, 819 

advantages of several punctures in, 819 

influence of number and quality of cica- 
trices on mortality after. 820 

mode of inserting virus, 823 

place of performing, 820, 824 
Revarciimtioji, necessity for, 821 

results of, 822 

period of performance, 821 
Vaccinia (.*e« Vaccine disease). 
Vacuole {see Bronchial abscess), 194 
Valerian in chorea 603 
Valleix. plan of examining abdomen, 46 

expectoration in true croup, 93 

emetics in true croup, 93 

on tracheotomy in croup, 107 

expectoration in pneumonia, 171 
Valvular diseases of heart {see Heart). 
Varicella, article on, 824-826 

definition of, 824 

synonyms of, 824 

forras'of. 824 

contagious nature of, 824 

epidemic nature of. 824 

essentially distinct from variola, 825 

symptoms of, 825 

eruption in, 825 

diagnosis of, 826 

prognosis in, 826 

treatment of. 826 
Variola, article on, 787-809 

definition of. 787 

frequency of. 787 

table of mortality of, 788 



1012 



INDEX. 



Variola, forms of, 788 

contagious nature of, 788 
epidemic nature of, 788 
transmitted by fomites, 789 
regular form of, period of incubation in, 
789 

symptoms of initial stage, 789 

pain in tlie loins in, 789 

symptoms of eruptive stage of, 790 

discrete and confluent forms of, 791 

date of appearance of eruption in, 
and character of papules in, 790 

development of eruption in, 790 

occurrence of eruption on mucous 
membranes, 791 

stomatitis in, 792 

laryngitis in, 792 

swelling of subcutaneous tissue in, 
792 
subsidence of general symptoms on ap- 
pearance of eruption, 792 

secondary fever. 792 

date of desiccation, 793 

date and modes of desquamation, 793 

pitting after, 793 

digestive symptoms during, 794 

urine in, 794 

excessive discharge of urine during 
desiccation, 794 

nervous symptoms in, 794 
irregular forms of, symptoms of initial 
stage, 794 

course of eruption in, 795 

haemorrhagic eruption in, 796 
modified (^ee Varioloid), 796 
complications of, 798 
anatomical lesions, 798 
condition of blood in, 798 

mucous membranes in, 798 
anatomy of pock in, 799 
diagnosis of, 799 
prognosis in, 802 
favorable symptoms in, 802 

unfavorable symptoms in, 802 
treatment of, 803-809 
mild febrifuges in mild cases, 803 
laxatives in, 804 

remedies for favoring appearance of erup- 
tion in, 804 
diet in, 804 
quinia in, 804 
opium in, 804 
stimulants in, 804 
treatment of complications in, 805 

of ophthalmia, 805 
ventilation and disinfectants in, 806 
prevention of pitting in, 806-809 
cauterization of pock with nitrate of 

silver, 806 
mercurial applications in, 808 
applications of solution of gutta percha 
in, 808 
Varioloid, definition of, 796 
symptoms of, 797 

course of eruption more rapid in, 797 
absence of secondary fever in, 797 




Varioloid, no pitting after, 792 
duration of, 797 
prognosis in, 802 
Venesection {see. Bleeding). 
Ventilation, importance of, in sick-chamber, 

781 

Vermifuges, 976-980 

Vesicles, chapter on, 903 ^B{ 

in variola, 789 fHl 

Virus, vaccine, forms of employed, and mode 

of introduction, 819 
Viscera, peculiar changes of in rickets, 872 
Voice, alteration of in coryza, 56 
in simple laryngitis, 62 
in false croup, 75 
in true croup, 91 
in diphtheritic paralysis, 675 
in congenital syphilis, 878 
Volvulus {see Intussusception), 456 
Vomicae, rare in tuberculosis of lungs, 850 
Vomiting, diagnostic signs from, 50, 51 
in gastritis, 377 
in entero-colitis, 396 
in entero-colitis, remedies for, 408 
in cholera infantum, 425 

treatment of, 430 
in intussusception, 461 
in typhoid fever, 2 

Water, importance of administering in pneu- 
monia, 189 
in cholera infantum, 432 
injections of, in intussusception, 469 
external use of, in scarlatina {see also 

Bath and Affusion), 746, 748 
local use of, in eczema. 914 
Wells, case of chronic trismus, 581 
Wertheimer, on oedematous angina, 348 
West, C, on statistics of pneumonia, 153 
on cerebral congestion, 510 
on characteristics of bronchial phthisis, 
854 
Wilson, Erasmus, description of acarus sca- 

biei, 925 
Woodward, J. J., on lesions in diarrhoea, 367 
microscopic changes in intestine in en- 
tero-colitis, 391 
use of mercury in diarrhoea, 403 
Woorara in tetan'^us, 583 

Worms in the alimentary canal, chapter on, 
965-982 
varieties of, 965 

description of ascaris lumbricoides, 965 
of ascaris vermicularis, 966 
of tricocephalus dispar, 966 
of taenia solium, 966 
lata, 967 
frequency of, much exaggerated, 967 
dangerous symptoms from, 968 
Worraseed oil as a vermifuge, 976 
Wunderlich, on temperature in scarlatina, 
754 

Zona {see Herpes zoster), 920 
Zymotic diseases, 651 



I 



u 



^a 



c c. 






Let,' 

?^| 

C cc c 
c* cc c 
C CCC 
c cc c 

<L c c c 

cccc 

cc cc 

CCCC 
cc c< 



'I: 
c c 



c c c 
CCLC 

< <^ c 
c<<C 
C'C C 

- c ''(^ C 

c«< c 



C(.c <> 

C CC * 

C C<^ < 
<^ c c < 
cccc 

C_ CC_ c 
r. c -c. * 
c c c ■ c 
:. cc c. 
c: cc < 

C cc < 

C cc < 

^ c c < 
C cc < 

c c ( < 
c << ^. ■ 

C:,C C < 

' CcCC' 
C c ( c 

CCJ. ^ 



c c < 

C C ' 

cc < 

C C 
c c 
C. C 

C d 

C C 

C C 

C ' 
C I 
c < 

C ^' 



: cc 

c c c 

C C C 

C ( c 
c cc 
c cc 

C CC ' 

rr cc 

c c c 

C cc 

< c c 

c c c 

c c c ^ 



' - cc 





(■ 


c 


,<c 


c 


r c 


(im 


V 


;', ( 


1^' 


(■ 


t^" 


<c 


c 


< c C 


■ €''€ 




( <s 


( 






■ C'' 


c 


r C 


(L € ■ 


C ( 


' <i. 


c 


'X 


f. 


'<^"V 


c 


^ c 


(i: € 


> 


< 


-^V , 


C 


< 


<ycc 


c 


' r c. 


(^< 




f ' < 


^0P^' ■' 


C 


( 


(Ti^CC 


c 


c 


<3l'«S 


*^. 
g^ ( 


( 


^■'C 


c 
c 
c 

< 


i 




c 
c 
c 

Cf 


c 
c 
c 
c 




C 
C 

c 


c 
c 

c 





CX< C c 
CCc C^ c 




^ 1 ' #^ 


^'^ 


c^ ^ 








'c'^V 


' C< CTcc c <: 






^l.i ^<! 


. d 

C 


^% 


-C 


■Q ~ 


c C^ 
c c 


c r<5 1 




: C- ct C 
c?^ «^ r 


c 

(( 


<r S ,^c 


c 
c 


C'C r r< 




c 

r 


C <; 

C C 


iV Cc c (Tv 

- C^ 'C i-^" 




_ o< <fr c- 

_ C^ C C' 


*4 


^1 ^4 


c^ 

c 

r 


<^cr 


c' 

■ c 


(- 


Cc 

^- c 


> c. ^<r (X- 

: C^ CC 


-^ ^^^^ 9 S 

^ c CI ^C Cj. < 

CC cxc o ;:^ 
c< ccc c: < 

cc e c c • 
cc e C' c 


:c c: c 


c 


P^ <d c 
^cc c c 

^<C cd C 

!d^<r oc c" 

> <d<31 d C 


V 

c 
c 

1 


^1 




k 


C ( 


C CC-c re 
^ -5'^ d: 

^-^; C Cr 
^<K'c o 




c 


=- 


yic# 


cc c c c ^ 


C7c f cT C 


cc < 


C dccdJ c 


€ 


> 


d! 








%^Z Cc 


C( C Cu C •' 
CCe cc C^ 


cjcdf^ 


;l t 


L dCCc^ 


^ 


— -- 


f 






f' 


^c< .(■ ^c 


CCC_ CC'V 




c c 
c c: 


^^^,^^^ 




\^ 




c 


c 


%.f; 


cc c c5 j^ 
ccc cc c 


" C' ft 


CC 


c^:^'^ 


c 




; \^ 


-. C c 


c 
C 




r 9 C c' ^ 


e <; Gc 


c 


c O e •' oc 






\ 


<r-- c . 


i c 


c c^ "^ 


C c. <^ ^ ^ 


r c c > 


cc 


: c: ic cc 




<: < 


,.- 


C- c 


c 


-f-^ V^ ' 


^ c c c ^ 2 

c cc o^c-^ 

c c c c c < 


CCC ■• 


9^ 


. ^«- cc 


•- "- 


c^ c 


■ . vC ■ 


C c ', 


c 


<:^'c-c 


CCC 


c 


IP^c 


'') 


1? 


eg 


•A^ c' 


d 

> c 
c 


<Mcc 
< <a cc 

■C <^'- f ■ ' 


<^ ^c C^-5 , 




cz < 


> C^^ dC 




c-d 




■r .- 


^ c 


<^ d c r 


C;C'^C ccc ;J 


f^C C ( 


cc 


CccdC 




C c 


' 'C 


>- ( i 


c 


^dcc 


CcCC cc J 


L_ s ^ 


cc 


^aCC 




C c 


c 


C ■' 


d 


Cdcc- 


cc C C C C ^^ 


c c 


: d^ vdc 


(.._-■ 


c c 


c 




c 


cr cc ' 


Ccc c c c ; 


dC C '^ 


C C 


c/ cc 




Cr 


c 


C 


dc cc 


re c C C c < 


r < 


d <^ 


: d cc 




Ci 


c 




c 

c 


cc cc 


ccch cc^ 
c:c c c c c 
cccc c: c 

CCTC: ^C 
C^ c c C C 
c c c ^ 5^ r 


C_c - 


c: 


c d cc 




C r 


c 




cc cc 




d ^ 


C C CC 




re 

cr 

C" 

c ■- 
Cj: 


c 

c 

c 

c 
r 


C 
C: 

c 

c 
c 


c 
c 

c 
d 


^ cc 
a: cc 

^ cc 


^h 


^ 


c; c cc 
c c/cc 




c 


< 


< 

c 


d 
< 


. cc cc 

^ d Cvc 




-^ c^c V 


^ 


c C ' c 




c 


l_ c 

c 


c 

- < 

c 








' CCC 


^ 


C O'C 


C 


c c; 


c 


d 


^ 

c 


-=.. C <: C 
C7 CC 


CCC 


V- 


C Ce-^ 


•C C 


: c Ca 


:c 




< 


C' (C 


ccc 


V; 


c t|r 




C 


c c. 


d 


< 


<-. C CC 


C ( c ^ 

r ( C C 


ccc 

^ CCC 

^ C f c 


<I^ 




, 


Cj 

c 


c 


^ 




^^ J> ^- 

^ Ccc 
C c^ ' r 


' ^ < 


d- ' 


^^ CC C 


C 


< C Q 


; d 


c: 


>C 4 


C c (C 


' 5^ € 


- r> 


^^J- 


d c"c c! 


C 


■ c ■ c 


c 


d 


'd 


d C f r 


. vC 1^ % ?• ^ 


1 




c 
c 

c 

c 


c c 

C C 
c < 
" . c 
c •■ , 


d 

cc 

2 c 
C 

c c 


d 


$- 

w 


let 

d c c r 




c c c 
C:- C C 
(C^ C c - 
cC C C J 

c:cc ^ 


r ^(f 


; "^ aC 

-£c^C^-. 


C ^ 


c 
C ( 

;. • c ( 

C ( 


0- c 

cC 

c 
c 


f 




d 

d Uv. 


c c 


'^ ^ 5 c^ 




d c 


c: 


c C 


d 


«®c 


c: cc<< 


r^ C^ 


(dec C 




d c 


(, 


(^ 


'^ c' 


d 


<^;.. 


Cl c = ( 


V c ^ 


^ c ^ 5 


^ / 


d c 




c 


Q C 


d 


<^L 


S 


*^ c^ <■ <* 


cCT c c C 




i d^ c 




V 


c C 


d 


c<m 


d 


> ^ < 


^:c c f c 


k 


; d c 




c 


{ c 


d 


<<gr. 


d 




cC^ -^ ^ 




c: c 




c 


^ ( 


d ' ' 


C4j|^ 


d 


^crcc c 


vCV 


^ c > 






; ( 


c < 


■^^J'. 


c ■: ■ '-^ ' 


t t ^r 


'^^Sf 




5 ^^ 


/■' 






C ^^ 


*^ 


d > c, 
^^ c 


c ^ c <^ 


'<y ^ 9 


.( 


C c d 


V 


, 


c < 


C-. -^ 


(^i-. 


d c 


C C ^ 


^c c 

<^ jC 

c c 

c c 
c c, 
c c 




(, 


(." 




c^,. 


i^ 


C '' 

c 


c c ^^- 
c r eQC 

c c ^c 




1 


C 

c 

c'_ ' 

r ( 


(C 
c C 

- c: 




cc, 

C C"< ' 


c.c- ^ 


i^&^ 


c ^' J 


sef 






c^<^C 




'c . •, 


C C' « 


n^^ 




"(■' 






C'-^dE^ 


r 




c c /^> 

c c «. 




1' 










. .^ 



